Form Tp105 - Parent/guardian Permission And Health History For Troop Outings
ADVERTISEMENT
1
2Girl Scouts – North Carolina Coastal Pines
6901 Pinecrest Road, Raleigh, NC 27613
(800) 284‐4475 or (919) 782‐3021
PARENT/GUARDIAN PERMISSION FOR TROOP OUTINGS TP105
Please complete this form and return to your daughter’s troop leader. Permission(s) and release information is
needed before your daughter can participate in Girl Scout troop activities. Please print legibly.
Girl’s Name
Troop#
Address
State
Zip
Parent’s/Guardian’s Name
Parent’s/Guardian’s Phone # (
)
‐
Cell Phone # (
)
‐
Emergency Contact Name/phone #
(*Someone other than the parent/guardian who we can call in an emergency.)
This permission is required for all troop activities away from the meeting place. My daughter/ward has my permission to participate in any
troop/group‐sanctioned or Girl Scouts‐North Carolina Coastal Pines‐sanctioned trip, event and activities during the 20
‐20
membership
year. I understand that I will receive information giving specific departure and arrival times, planned activities, contact persons, and any
other pertinent information prior to any trip or event.
I agree that pictures or videos of my daughter/ward may be used to promote the Girl Scout program.
Yes
No
GSUSA provides activity accident insurance as secondary coverage to the family’s own insurance coverage.
Custody Type: (select one)
Both Parents
Mother only
Father only
Other
My child may be picked up by:
Signature of Parent or Legal Guardian
Date/Updated Date
HEALTH HISTORY FOR GIRLS
Girl’s Name
Date of Birth
Age
Girl’s Physician
Telephone # (
)
‐
Family Medical/Hospital Insurance Carrier
Policy #
Group #
For the safety of your child, is there a condition that you would like us to know (e.g., nosebleed, emotional disturbances, menstrual cramps,
motion sickness, etc.)?
Is your daughter currently under a physician’s care for a medical problem? If so, explain: (optional)
List any allergies your daughter/ward may have (i.e., pollen, insect stings, etc.)
.
Is your girl current with her immunizations (check one)
______ YES
_______ N O
______ Choose not to immunize.
Authorization for Treatment: I hereby give permission to the medical personnel selected by the Girl Scout adult in charge to order X‐rays,
routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related
transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the
Girl Scout adult in charge to secure and administer treatment, including hospitalization, for the person named above. This completed form
may be photocopied for use off‐site.
Signature of parent/guardian of minor
Date/ Updated Date
TP105/09‐2017
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business