Girl Scouts Of Citrus Council, Inc. Gsusa Girl Troop Health History Form

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Girl Scouts of Citrus Council, Inc.
GSUSA GIRL HEALTH HISTORY
Name (Last, First, Initial)
Parent or Guardian
Phone(s)
Address
City or Town
State
Zip
Birth
Age
Sex
In Emergency Notify
Address
Phone (s)
Health History: (Check those that apply)
Diseases
Allergies
Chronic or Recurring Illness
Suggestions From Parent:
My daughter has permission
to take or use the following:
Please describe conditions and give dates:
Comment where applicable:
A health examination within the preceding 24 months is required for participation in
a trip of more than three nights (page 39 – Safety-Wise).
Signature of Parent/Guardian _________________________________ Date ___________________________

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