Adult Health History Card - Girl Scouts Of Connecticut Page 2
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2GIRL SCOUTS OF CONNECTICUT
GIRL SCOUTS OF CONNECTICUT
GIRL SCOUTS OF CONNECTICUT
Person to call in case of an emergency:______________________________
Person to call in case of an emergency:______________________________
Person to call in case of an emergency:______________________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
Alternate person to call:__________________________________________
Alternate person to call:__________________________________________
Alternate person to call:__________________________________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
In case the people listed above can not be reached, do you give permis-
In case the people listed above can not be reached, do you give permis-
In case the people listed above can not be reached, do you give permis-
sion to have any necessary medical treatment administered, including
sion to have any necessary medical treatment administered, including
sion to have any necessary medical treatment administered, including
surgery or anesthesia?
surgery or anesthesia?
surgery or anesthesia?
YES_________________ NO________________
YES_________________ NO________________
YES_________________ NO________________
Signature:_______________________________Date:_________________
Signature:_______________________________Date:_________________
Signature:_______________________________Date:_________________
Physician:_______________________________Phone:________________
Physician:_______________________________Phone:________________
Physician:_______________________________Phone:________________
Insurance Carrier:______________________________________________
Insurance Carrier:______________________________________________
Insurance Carrier:______________________________________________
GIRL SCOUTS OF CONNECTICUT
GIRL SCOUTS OF CONNECTICUT
GIRL SCOUTS OF CONNECTICUT
Person to call in case of an emergency:______________________________
Person to call in case of an emergency:______________________________
Person to call in case of an emergency:______________________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
Alternate person to call:__________________________________________
Alternate person to call:__________________________________________
Alternate person to call:__________________________________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
In case the people listed above can not be reached, do you give permis-
In case the people listed above can not be reached, do you give permis-
In case the people listed above can not be reached, do you give permis-
sion to have any necessary medical treatment administered, including
sion to have any necessary medical treatment administered, including
sion to have any necessary medical treatment administered, including
surgery or anesthesia?
surgery or anesthesia?
surgery or anesthesia?
YES_________________ NO________________
YES_________________ NO________________
YES_________________ NO________________
Signature:_______________________________Date:_________________
Signature:_______________________________Date:_________________
Signature:_______________________________Date:_________________
Physician:_______________________________Phone:________________
Physician:_______________________________Phone:________________
Physician:_______________________________Phone:________________
Insurance Carrier:______________________________________________
Insurance Carrier:______________________________________________
Insurance Carrier:______________________________________________
GIRL SCOUTS OF CONNECTICUT
GIRL SCOUTS OF CONNECTICUT
GIRL SCOUTS OF CONNECTICUT
Person to call in case of an emergency:______________________________
Person to call in case of an emergency:______________________________
Person to call in case of an emergency:______________________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
Alternate person to call:__________________________________________
Alternate person to call:__________________________________________
Alternate person to call:__________________________________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
Day phone:____________________Evening phone:___________________
In case the people listed above can not be reached, do you give permis-
In case the people listed above can not be reached, do you give permis-
In case the people listed above can not be reached, do you give permis-
sion to have any necessary medical treatment administered, including
sion to have any necessary medical treatment administered, including
sion to have any necessary medical treatment administered, including
surgery or anesthesia?
surgery or anesthesia?
surgery or anesthesia?
YES_________________ NO________________
YES_________________ NO________________
YES_________________ NO________________
Signature:_______________________________Date:_________________
Signature:_______________________________Date:_________________
Signature:_______________________________Date:_________________
Physician:_______________________________Phone:________________
Physician:_______________________________Phone:________________
Physician:_______________________________Phone:________________
Insurance Carrier:______________________________________________
Insurance Carrier:______________________________________________
Insurance Carrier:______________________________________________
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