Girl Scouts Of Silver Sage Council Health History Form
ADVERTISEMENT
1
21410 Etheridge Lane
Boise, ID 83704
HEALTH HISTORY FORM
(208) 377-2011 or (800) 846-0079
Girls and adults fill out only this side for events of two nights or less or three nights over a
Fax: (208) 377-0504
Federal holiday. See other side (Health Examination Form) for events lasting longer than that.
Camper Name (Last, First, MI of girl or adult)
Parent/Guardian if camper is a minor
(Area Code) Phone
Address
City
State
Zip Code
Date of Birth
Age
Sex: M or F
Emergency Contact Person/Relationship
(Area Code) Phone
Cell Phone
Work Phone
Health History (Check if applicant has had any of the following)
DISEASES
CHRONIC/RECURRING ILLNESS
___ Measles
___ Mumps
___ German Measles
___ Diabetes
___ Ear Infections
___ Musculoskeletal Disorder
___ Hepatitis A
___ Hepatitis B
___ Hepatitis C
___ ADD/ADHD
___ Heart Defect
___ Sleep Disorders
___ Chicken Pox
___ Lice
___ Seizures
___ Menstrual Cramps
___ Nose Bleeds
___ Asthma
___ Eating Disorders
_______ TB Test Date/Result: ________
___ Fainting
___ Hypertension
___ Other (Specify)
Operation or serious injuries (dates):
IMMUNIZATIONS
ALLERGIES
(Use other side as needed)
___ Animals
___ Insect Stings
___ Pollen
Are required school immunizations up to date?
Yes 0
No 0
If your camper has not been fully immunized, please sign the following
___ Food
___ Medicine
___ Other
statement: I understand and accept the risks to my child from not being
___ Hay Fever
___ Plants
fully immunized.
_________________________________________________________________ _________
Signature of Adult Camper or Parent/Guardian if camper is a minor
Date
List important details, especially allergic reactions to stings, food and drugs: (Attach additional sheet if needed.)
Insurance information needed in case of emergencies: Is participant covered by family medical/hospital insurance?
Yes 0
No 0
Insurance carrier or plan name__________________________ group #_______________________ name of insured_______________________________
MEDICATION PERMISSION RELEASE
We have Health Services Staff on site while campers are at camp. Please check all over-the-counter (OTC) medications camper is allowed to use. These are
Unless instructed otherwise, we will follow the directions on the medication for dosage.
available at camp; you do not need to supply them.
Please indicate
whether or not we have permission to administer over-the-counter (OTC) medications if the need arises.
Over-the-Counter (OTC) Medications
Dosage
o
I want
to receive or have my camper receive listed OTC medications if the need arises.
Acetaminophen (pain, fever)
o
I do not want
to receive or have my camper receive any OTC medications without prior
Ibuprofen (pain, fever, inflammation)
permission from me.
Pseudoephedrine (decongestant)
Diphenhydramine (antihistamine)
Dextromethorphan (cough)
__________________________________________________________________________________
Signature of Adult Camper or Parent/Guardian if camper is a minor
Date
Calamine Lotion (anti-itch)
Antacid Tablets (upset stomach)
ANY PRESCRIPTION and OVER-THE-COUNTER (OTC) MEDICATIONS YOU ARE SENDING TO CAMP WITH YOUR CAMPER
original container
must be in
with name, address of camper, pharmacy, dosage and frequency. This includes OTC vitamins, medications for motion
sickness, mosquito bite relief, etc. Place all labeled meds (prescription and over-the-counter) in a plastic zipper bag with camper’s name on the bag. Please
indicate if camper needs to carry and administer own medications for emergency treatment such as bronchial inhaler, EpiPen or diabetes medications.
If you need more space, please attach separate sheet with the following information.
Medication (Name of Drug)
Reason for Medication
Emergency Self Medicate?
_____________________________________________________________________
Yes 0
No 0
_____________________________________________________________________
Yes 0
No 0
_____________________________________________________________________
Yes 0
No 0
_____________________________________________________________________
Yes 0
No 0
Consent: This health history is correct as far as I know, and camper has permission to engage in all prescribed camp activities, except as noted. Camper
is in good health. I give permission to receive or have my camper receive treatment for routine medical and/or first aid needs. In the event I cannot be
reached in an emergency, I give my permission for my camper __________________, to receive emergency medical treatment and surgical treatment and
to be hospitalized, if necessary. It is understood every effort will be made to contact me or the emergency contact noted above, before taking this action.
All medications being taken by camper are listed on this form. I agree to the release of any records necessary for treatment, referral, billing or insurance
o
I agree
or
o
I do not authorize medical consent.
purposes. This completed form may be photocopied for trips away from camp
.
_______________________________________________________
___________________________________
Signature of Adult Camper or Parent/Guardian if camper is a minor
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business