Health History Form
Thank you, we have received your registration for Houchens Day Camp. Please fill out the following Health History Form. We need one filled out for everyone at camp, including adult volunteers.  
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Girl Scout Name *
Birthday *
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Custodial Parents/Guardians Names *
Parent/Guardian Email *
Home/Cell Phone *
Work Phone
Name of Emergency Contact other than parent/guardian *
Relationship to Girl Scout *
Emergency contact Home/Cell Phone *
Emergency contact Work Phone
Girl Scout’s Physician *
Physician Office Phone *
Insurance Carrier *
Policy # *
Group # *
If hospitalization is required, take Girl Scout to *
Allergies: Check those that apply *
Required
Specify nature and if treatment to allergies listed requires the use of an Epipen ®, Benadryl, etc.
Illnesses, Injuries or Health Conditions: Check  those that apply *
Required
If you checked yes to any illnesses, injuries or other health conditions, please give nature, dates, period of any disability and results. Also, list any activities that should be restricted.
Immunizations *
Date of last Tetanus shot: *
Permission for Medications: Girl Scout may take the following medications: *
(check those that apply)
Required
Is Girl Scout taking any medication? *
Information about Medications: If yes, a list of the Girl Scout’s current medications will be required to be delivered to the Camp Nurse prior to camp; send a list of any medication changes or updates when needed.➢Medications for Girl Scouts under the age of 18 must be kept in the possession of the volunteer at all times (unless otherwise noted).➢Any medication to be dispensed should be indicated on the Health History Form or other written form.➢All medication, including over-the-counter products, should be in the original container and marked clearly with the participant’s name and directions for use.➢Prescribed medications and over-the-counter products must be administered in the prescribed dosage in the presence of the volunteer as per the written instructions of a custodial parent, a guardian, or a physician.➢Medication can only be dispensed to the person named on the prescription container.➢As per the Safety-Wise chapter of Volunteer Essentials, medications, including over-the-counter products, cannot be dispensed without prior written permission from a girl’s custodial parent or guardian.
Parent/Volunteer Verification *
By Submission of this form and registration for the activity, I verify: My Girl Scout has had a physical examination within the past 24 months and is in good health. I give full permission for my Girl Scout to participate in all activities (except as noted on this health history.) The Girl Scouts of Kentuckiana is held harmless in the event of an accident. In the case of injuries, I give permission for medical treatment as deemed necessary. Permission is granted to use any pictures or video footage of my Girl Scout for Girl Scout promotional purposes. I agree that all information including immunizations is complete and up to date.Volunteer Statement & Signature - I am in good health and able to participate in all activities except as noted on this health history. The Girl Scouts of Kentuckiana is held harmless in the event of an accident. In the case of an injury, I give permission for medical treatment as deemed necessary. Permission is granted to use any pictures or video footage of me for Girl Scout promotional purposes.    HEALTH INFORMATION PRIVACY STATEMENT FROM GSUSA      The Health History Form is for health care concerns at this troop only. All medical records will be held in limited access by the volunteer in charge. Minimally necessary information may be shared with volunteers in order to provide adequate participant safety and health care.
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