Travel Health Form
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3Travel Health Form
This form is used by girls and advisors for travel of 3 or more nights, unless travel occurs over a US Federal Holiday
weekend. Please be complete in the information provided to ensure proper medical care. A medical examination must be
completed by a licensed physician, nurse practitioner, physician’s assistant or registered nurse within the preceding 24 months
unless a health issue is present. For international travel, this form must be completed within 12 months. Groups traveling to
Canada for less than 3 nights can forgo this form but must still complete all necessary paperwork for short trips.
Participant Information
Full Legal Name: _______________________________________Birthdate:_____________ Gender:
Female
Male
Address:__________________________________
City:______________________
State:_______
Zip:__________
Phone Number:________________________ Email: ________________________________________________________
Primary Emergency Contact:
Secondary Emergency Contact:
Relationship:
Relationship:
Phone 1:
Phone 1:
Phone 2:
Phone 2:
Health Insurance Information
In case of accident or illness, personal insurance is primary, Girl Scout insurance is secondary
Policy Holder’s Name: _______________________________
Policy Number: ___________________________________
Insurance Company Name: ___________________________
Group Number: ___________________________________
Insurance Company Address: _________________________
Insurance Company Phone: _________________________
Medical History
Check all that apply and explain in detail checked answers – use extra paper if necessary
Diabetes
Sleep Disturbances
Eating Disorders (Anorexia, Bulimia)
Heart Defects/Disease
Eyesight Impairment
Headaches/Migraines
Asthma
Hearing Impairment
Intestinal Disorders/Constipation
Diseases of the Ear or Ear Infections
Speech Impairment
Arthritis
Musculoskeletal Disorders
Chicken Pox
Nosebleeds
Convulsions/Epilepsy/Seizures
Measles
Hernia
Sinusitis (Sinus Infections)
German Measles
Menstrual Cramps
Physical Restrictions
Mumps
Bleeding Disorder
Had surgery/hospitalized in the last 5
Kidney/Bladder Illness
Rheumatic Fever
years
Mental/Psychological Disorder
Tuberculosis
Currently under doctor’s care
Hypertension/High Blood Pressure
Kidney Disease
Other:
Please explain any items checked above:
Medical Conditions and/or Concerns
Please include any precautions or restrictions on activities, as well as concerns relating to emotional and mental well-being
(including self-harm, depression, effects of medication on their behavior, eating disorders, etc.). We want to provide the most
supportive environment possible, and a large part of that knows what’s going on with trip participants. The more information
you provide, the better we are able to work with you to establish a plan.
Name of Condition
Effects
Additional Information or Comments:
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Parent category: Business