Girl Scouts Of Kansas Heartland Health History And Authorization Form Page 2
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3Participant’s Name:
Medications: List any medications the participant is currently taking (or has taken in the recent past) including dosage schedule
and specific instructions for use. No child shall keep medication in her possession; it must be turned in to the adult in charge in
original packaging or prescription bottle with directions.
Medication
Purpose
Dosage Schedule
Specific Instructions
1.
2.
3.
4.
5.
Over-the-Counter Medications: The participant has permission to take over-the-counter medications in case of accident or
injury. Please check all that (s)he has permission to take:
Special considerations or notes
Tylenol/Acetaminophen
Imodium (anti-diarrhea)
regarding over-the-counter medications:
Aspirin (fever reducer)
Dramamine (motion sickness
Ibuprofen (pain/swelling)
prevention)
Benadryl/Antihistamine
Skin Ointments (in case of rash,
antibacterial, athlete’s foot, etc.)
Robitussin/expectorant
Other:
Sudafed/decongestant
Pepto Bismol
Other:
Tums/antacid
Does the participant have a special medical or dietary regiment to be followed?
Yes
No
If so, please explain:
Has the participant ever had any adverse reactions to general anesthetics?
Yes
No
If so, please explain:
List any other information not covered in this form that is important for troop volunteers or program staff to know:
_
CONSENT TO MEDICAL TREATMENT:
I, ________________________, participant or parent/legal guardian of minor participant _______________________, do hereby consent to any
hospital, medical, or surgical care and treatment, and the administration of anesthesia, determined by a qualified physician to be necessary for the
welfare of myself or my child while said child is under the care, custody, and control of a Girl Scout adult, and I am not reasonably available by
telephone to give consent.
INITIAL HERE:
HEALTH INFORMATION PRIVACY STATEMENT
The Health History and Authorization Form is for health care concerns at Girl Scout activities. All records will be handled by troop volunteers or
program staff whose job includes processing or using this information for the benefit of the participant. Necessary information may be shared with
additional volunteers or program staff in order to provide adequate participant safety and health care during Girl Scout activities. This form may be
retained by Council according to Kansas state law; access to the information will be limited, but copies may be requested from the event sponsor, by
the participant, or their legal representatives. I have read the above procedures for handling the health and medical form and I agree to the release
of any records necessary for treatment, referral, billing, or insurance purposes.
INITIAL HERE:
MEDIA PERMISSION:
When participating in Girl Scout activities the participant or parent/guardian of minor participant gives consent to be interviewed, photographed,
videotaped, or electronically imaged for the purposed of promotional materials, news releases, or other published formats for either the local Girl
Scout Councils or Girl Scouts of the USA. I hereby release and hold harmless Girl Scouts of Kansas Heartland and Girl Scouts of the USA from any
claim arising from the use of these images.
INITIAL HERE:
This Health History and Authorization Form is complete and accurate. The participant has permission to engage in all Girl Scout activities,
except as noted.
Signature of Participant or Parent/Guardian of Minor Participant:
Date:
4/2016
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