Form Prog076.1 - Girl/adult Health History Form Page 2
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When participating in Girl Scout activities the registrant may be photographed for print, videotaped, or electronically imaged. Images may be
used in promotional materials, news releases, and other published formats for either the local Girl Scout Councils or Girl Scouts of the USA. The
images will be the sole property of either the local Girl Scout Council or Girl Scouts of the USA.
I give permission to the registrant to be photographed, videotaped or otherwise electronically imaged.
I DO NOT give permission for the registrant to be photographed, videotaped or otherwise electronically imaged.
Signature of Parent/Guardian___________________________________________________________________________Date____________
Authorization
Parent/Guardian Authorization Check One:
___In the event that my child needs medical attention while participating in Girl Scout activities, I authorize the adult in charge to see that my
child receives reasonable first aid and to transport my child to a health care facility for emergency services as needed.
___I DO NOT authorize MEDICAL CONSENT and understand this information will be in the Leader’s possession during Troop/Group meetings,
day camps, and special events.
Signature of parent/guardian___________________________________________________________________________Date____________
Adult Member Authorization
This health form is complete and accurate. I am able to engage in all prescribed activities except as noted.
Signature of adult____________________________________________________________________________________Date____________
PROG076.1 (8/2012)
Troop Leader—Please retain for your records
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