Girl/adult Health History Form

Girl/Adult Health History Form

GIRL MEMBER

ADULT MEMBER

PLEASE PRINT CLEARLY IN INK.

Troop #:

or Individual

Service Unit:

First Name:

Middle Name:

Last Name:

Mailing Address:

Apt. #:

PO Box:

City:

State:

Zip:

Phone: (

)

Cell: (

)

E-mail:

Parent/Guardian(s) Name and address (If different from girl’s): (Complete for girl form only)

1.

Phone: (

)

Cell:

(

)

Parent/Guardian(s) Name and address (If different from girl’s): (Complete for girl form only)

2..

Phone: (

)

Cell:

(

)

Custodial Care Information:

Both Parents

Mother Only

Father Only

Other:_________________________________________________

P

Name of Family Physician:

Phone: (

)

Family Medical/Hospital Insurance Carrier:

Policy or Group No:

Family Dental Insurance Carrier:

Policy or Group No:

Health Information: Age:___________ Date of birth:

/

/

Immunizations are up to date.

MM

DD

YY

Date of last Tetanus shot:

/

/

MM

DD

YY

Date of last health examination:

Were there any medical problems at the time?

Does participant have any physical, mental or psychological conditions requiring medication, treatment, or other special restrictions or considerations?

Yes

No If yes, please state medication and reason:___________________________________________________________________________________

Does participant take any prescribed medications or over-the-counter drugs on a regular basis?

Yes

No If yes, please state medication and reason:___________________________________________________________________________________

Is participant restricted or limited from participating in any physical activity?

Yes

No If yes, please explain:_______________________________________________________________________________________________________

Please provide a record of past medical treatment, if any, including injures or surgeries:

Participant has the following health conditions/allergies/dietary restrictions (food and medications):

Participants with allergies must fill out an Allergies

ADHD

Asthma

Diabetes

Headaches

Seizures

Other:___________________________________________________________________

and Anaphylaxis Action Plan form, found under

Allergies (specify):_____________________________________________________________________________________________________________________

Forms + Documents at .

Emergency Contact (non-parent):

Relationship:

Phone: (

)

Cell: (

)

PARENT/GUARDIAN AUTHORIZATION

This health form is complete and accurate. I know of no reason(s), other than the information indicted on this form, why my daughter/girl should not participate in the

prescribed activities except as noted. In the event that my daughter/girl needs medical attention while participating in Girl Scout activities, I authorize the adult in charge to

see that my daughter/girl receives routine healthcare, medications, reasonable first aid and to transport my child to a health care facility for emergency services as needed.

Signature of parent/guardian:

_______________________________________________________________________

Date:_______________________________

ADULT MEMBER AUTHORIZATION

This health history is complete and accurate. I am able to engage in all prescribed activities except as noted.

Signature of adult member:

_______________________________________________________________________

Date:_______________________________

Parent - please retain a copy for day camp, resident and other overnight camp programs.

Troop Leader - please retain for your records