Girl Scout Medical Information - Girl Scouts Of San Jacinto Council Page 2

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PART IV

(Please complete or attach a copy of this child’s Immunization Record)

Immunization/Disease History

Immunization

Year Primary Series Completed

Year of Last Booster

Has had Disease

D.T.P.

Diphtheria

Pertussis (whooping cough)

Tetanus

Td (tetanus/diptheria)

Measles

Mumps

Rubella (German Measles)

Chicken Pox

Oral Polio

Hib

Hepatitis B

Tuberculin Test Result (most recent)

Other

Listed are medication(s) my child will routinely take with the supervision of the Leader/First Aider.

(Attach a list if necessary.)

Medication:

Dosage:

How Often:

(indicate girl’s name) will self-administer.

Epi-pen

Bronchial inhaler

Diabetic medication

Please specify dosage and frequency:

Over the Counter Medication(s):

She can have: ________________________________________________________________________________________

She cannot have: _____________________________________________________________________________________

Parent’s/Legal Guardian’s Authorization: This health history is correct so far as I know, and the person herein described has permission to engage

in all planned trip activities except as noted by the examining physician or me.

TRANSPORTATION RELEASE: I authorize transportation for my child by emergency vehicle to an appropriate health care facility and pre-hospital

medical care, all hospital and physician services, whether medical, surgical and/or dental, necessary for the benefit/safety/well-being of my child. It is my

expressed intention to hold Girl Scouts of San Jacinto Council harmless for any and all injuries, death or damages arising from or in any way related to

any such transportation.

CONSENT TO TREAT: I hereby give permission to the physician selected [by the trip coordinator] to order X-rays, routine tests and treatment for

the health of my child, in the event I cannot be reached in an emergency. I hereby give permission to the physician selected by the first aider/trip

coordinator to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for my child as named above.

The information disclosed on this form may be released to Volunteer/Staff responsible for this activity including, but not limited to troop/group leaders,

drivers, medical personnel, etc.

My signature confirms that the above information is correct to the best of my knowledge and that I am authorized to execute the information form

and release.

Signature of Parent / Legal Guardian

Full Name of Child

Relationship to Child

Date

Day

Evn

Cell

Print Name of Parent/Legal Guardian

Address