Girl Scouts - Dakota Horizons :: HEALTH AND PERMISSION CARD

Completed by parent/guardian and reviewed with physician at time of examination.

Please complete girl's information in the fields below.

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    HEALTH HISTORY

    (Check those that apply)
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    PARENT/GUARDIAN AUTHORIZATION

    This health history is complete and accurate, and the person herein described has my permission to engage in all prescribed activities, except as noted by me. In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician named above, or if not available, to the physician selected by the adult in charge, to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child as named above. Please update and sign annually.
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    HOLD HARMLESS AGREEMENT

    I hereby release and hold harmless Girl Scouts—Dakota Horizons from any and all claims or liability arising from, out of or associated with my child’s participation in the activity (s) listed on this card. My signature should be placed next to each event on the back of this form evidencing my release of the Council, its agents and employees as to that specific activity.
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    Parent or Guardian Permission for Participation in Girl Scout Activities

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    My daughter has permission to participate in the Girl Scout activity listed below.

    I will make sure she does not attend if she is not feeling well.
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