Girl Scouts - Girl Health History printable pdf download

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-P

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IRL

COUTS

RIZONA

ACTUS

INE

OUNCIL

GIRL HEALTH HISTORY

council emergency # (602) 531-5935

Please note any health condition or concern that should be considered in her activities.

Girl Scout

Asthma

Heart Disease

Address

Diabetes

Glasses/Contact Lenses

Convulsions

Kidney/Bladder Problems

Phone

Alt Phone

Other:

Troop Leader

Troop#

Other:

Parent/Guardian

Allergies

(Please Specify)

If the parent/guardian cannot be reached, the following person is authorized

Animals

to act on their behalf:

Medicine/Drugs

Foods

Name

Hay Fever

Phone

Alt Phone

Insects Stings

Address

Other

City

State/Zip

The following information is commonly requested by the emergency

treatment facility:

I know of no reason(s), other than the information indicated on this form, why

Date of Birth

my daughter should not participate in prescribed activities except as noted. If I

cannot be reached in the event of any emergency, the troop leadership

Approximate Date of Last Tetanus Shot

may act on my behalf by providing for emergency medical treatment

and/or transportation.

Name of Doctor/Healthcare Provider

Phone

Name of Insurance Provider (if any)

Policy/Group #

Signature of Parent/Guardian

Date

MS-28

GSACPC, Inc.

03/08

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, I

IRL

COUTS

RIZONA

ACTUS

INE

OUNCIL

GENERAL PERMISSION

is my/our daughter or a girl in my/our legal custody. I/we have full authority to give this permission. She has my/our

permission to participate in all Girl Scout program and activities conducted or sponsored by Troop #

, to which she is registered, or which are conducted

or sponsored by the Girl Scouts–Arizona Cactus-Pine Council, Inc.

In case of sickness or accident, I/we, give permission for medical attention and the administration of medication and treatment as prescribed by the girl’s

physician or as determined by an available physician, nurse, health professional or first aider.

She needs or may need any of the following medications, i.e. inhaler, Epipen, dietary needs, or specific accommodations during her activity participation

with her troop or individually:

(Write “NONE” if there are none.)

Physicians, nurses, health professionals or first aiders MAY NOT administer the following medicines or treatments:

(If there are no prohibitions or restrictions write “NONE”.)

Signature of Parent/Guardian*

Date

Signature of Parent/Guardian*

Date

Address

Telephone

Alt Telephone

Telephone