Girl Scouts Of Gulfcoast Florida Consent Form
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2Girl Scouts of Gulfcoast Florida, Inc.
CONSENT FORM
The following person(s) is AUTHORIZED to pick up my child:
Name ______________________________________________________ Relationship ___________________________________________________
The following person(s) is FORBIDDEN to pick up my child:
Name ______________________________________________________ Relationship ___________________________________________________
EMERGENCY CONTACT INFORMATION
In case of emergency notify: _________________________________________________ Relationship ____________________________________
Home phone (_________)______________________________
Work phone
(_________)______________________________
Cell phone
(_________)______________________________
Address __________________________________________________________ City ______________________ State _______ Zip _____________
My daughter fully understands that she is not allowed to give any medications that she has with her to any other
person and will inform the person in charge of first aid when she has taken any of this medication herself.
This health history is complete and accurate to the best of my knowledge. I affirm that my child’s immunizations
are up to date.
This consent form serves as permission for my daughter to participate in all Girl Scout activities unless otherwise
noted by me in writing.
Signature of parent/guardian __________________________________________________________________ Date ______/______/___________
Pathway leaders please keep a copy of Consent Form and Girl Registration Form in your records.
Forms must accompany you when you attend meetings, field trips, or a council sponsored program event.
4780 Cattlemen Rd., Sarasota, FL 34233
941-921-5358 • 800-232-4475
C:SHELFFORMS/2015Forms/ConsentForm ~ Rev. 6/15
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