Form Tp105 - Parent/guardian Permission And Health History For Troop Outings Page 2
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1
2Girl’s Name
MEDICATION PERMISSION AND INSTRUCTIONS
Written parental consent is required before a minor (under 18) Girl Scout may be given any medication or treatment of any kind. During
trips or at events, girls may need medication for ailments such as headaches, stomachaches, diarrhea, or a low‐grade fever. They might
need sunscreen, insect repellent or Chapstick. You MUST send any over‐the‐counter medication your daughter may need in the original
bottle/package (INCLUDING ASPIRIN, TYLENOL, ETC.). Prescription drugs must be in the original bottle/package with the physician’s
instructions for administering them. Put all drugs in their original bottle/package in a Ziploc bag and label it with your daughter’s name.
Medication will be available from the adult in charge of first aid and can be given as specified by instructions on the label for prescription
drugs or by written instructions from parents/guardians for over‐the‐counter drugs. Complete the middle part of this form with
instructions for over the counter drugs.
Girls may keep asthma sprays, epi‐pens, insect repellent, or sunscreen with them if they know how to use them with prior written
permission from parents or from the adult in charge of first aid. All other medication must be turned into the adult in charge of first aid,
unless we have a note signed by a physician stating that a girl must keep a certain medication with her.
It is the responsibility of the girl/parent to make sure all medication is picked up at the end of the trip/activity/camp.
List all over‐the‐counter and/or prescription medication that your daughter will have at this trip/activity/camp.
Give exact instructions for administering over‐the‐counter medications.
*We cannot administer over‐the‐counter medication without written instructions.
MEDICATION
Prescribed
INSTRUCTIONS
INITIAL/DATE
(original container with doctor’s orders)
(original container with doctor’s orders)
(original container with doctor’s orders)
(original container with doctor’s orders)
Over the counter
INSTRUCTIONS
INITIAL/DATE
Medication/chemical treatments recommended by the American Red Cross:
The following items are recommended by the American Red Cross as the appropriate treatment for these conditions. Initial each
treatment you want your daughter to receive, if needed. These medications should be available in trip/activity/camp first aid kits. No
other medication is available unless sent with your daughter.
Poisoning
Activated Charcoal ‐ administered as
directed by the Carolina Poison Control Center, 1‐800‐848‐6946.
Small wounds, cuts,
Antibiotic ointment
animal or tick bite, minor burn
Poison Ivy
Topical antihistamine such as Caladryl or Benadryl
Marine life stings
Baking soda and salt water
Sunburn
Aloe gel
Insect bites
Topical antihistamine such as Benadryl
I give my permission for my daughter/ward,
, to take the medications listed above and, if needed,
to have any of the treatments I have initialed.
Signature of Parent or Legal Guardian
TP105/09‐2017
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