Request edit access
2022 Girl/Adult Health History Form
Sign in to Google to save your progress. Learn more
Email *
Member
Clear selection
Troop #:
Service Unit:
Clear selection
CONTACT INFORMATION
First Name
Middle Name:
Last Name
Mailing Address:
City:
State:
Zip Code:
Phone:
Cell Phone:
Email
1. Parent/Guardian(s) Name and address (if different from girls): Complete for girl form only.
Phone:
Cell Phone:
2. Parent/Guardian(s) Name and address (if different from girls): Complete for girl form only.
Cell Phone:
Signature
Custodial Care Information
Clear selection
HEALTH INFORMATION
Name of Family Physician:
Phone #:
Family Medical/Hospital Insurance Carrier:
Policy or Group No.:
Family Dental Insurance Carrier:
Policy or Group No.:
Age:
Date of Birth
Immunizations are up to date.
Clear selection
Date of last Tetanus shot:
Date of last health examination:
Were there any medical problems at the time?
Does participant have any physical, mental or psychological conditions requiring medication, treatment, or other special restriction or considerations?
If yes, please state below.
Does participant take any prescribed medications or over-the counter drugs on a regular basis?
If yes, please list Medication/Dose, Reason for Medication, Times and day to be given as needed or prescribed and if it's a Prescription or Over-the-Counter. Please note, we can only administer prescirption medication according to the directions on the label, unless we have a signed doctor's note.
Is participant restricted or limited from participating in any physical activity?
If yes, please state below.
Please provide a record of past medical treatment, if any, including injures or surgeries.
Participant has the following health conditions/allergies/dietary restrictions (food or medication)
Allergies:
Emergency Contact (non-parent)
Relationship:
Phone:
Cell:
PARENT/GUARDIAN AUTHORIZATION
This health form is complete and accurate. I know of no reason(s), other than the information indicated on this form, why my daughter/girl should not participate in the prescribed activities except as noted.  In the event that my daughter/girl needs medical attention while participating in Girl Scout activities, I authorize the adult in charge to see that my daughter/girl receives routine healthcare, medications, reasonable first aid and to transport my child to a health care facility for emergency services as needed.
Signature of parent/guardian:
Date:
ADULT MEMBER AUTHORIZATION
This health history is complete and accurate.  I am able to engage in all prescribed activities except as noted.
Signature of adult member:
Date:
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy