2019 Girl/Adult Health History Form
Member
Troop #:
Your answer
Service Unit:
CONTACT INFORMATION
First Name
Your answer
Middle Name:
Your answer
Last Name
Your answer
Mailing Address:
Your answer
City:
Your answer
State:
Your answer
Zip Code:
Your answer
Phone:
Your answer
Cell Phone:
Your answer
Email
Your answer
1. Parent/Guardian(s) Name and address (if different from girls): Complete for girl form only.
Your answer
Phone:
Your answer
Cell Phone:
Your answer
2. Parent/Guardian(s) Name and address (if different from girls): Complete for girl form only.
Your answer
Cell Phone:
Your answer
Signature
Your answer
Custodial Care Information
HEALTH INFORMATION
Name of Family Physician:
Your answer
Phone #:
Your answer
Family Medical/Hospital Insurance Carrier:
Your answer
Policy or Group No.:
Your answer
Family Dental Insurance Carrier:
Your answer
Policy or Group No.:
Your answer
Age:
Your answer
Date of Birth
Your answer
Immunizations are up to date.
Date of last Tetanus shot:
Your answer
Date of last health examination:
Your answer
Were there any medical problems at the time?
Your answer
Does participant have any physical, mental or psychological conditions requiring medication, treatment, or other special restriction or considerations?
If yes, please state below.
Your answer
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.
Your answer
Is participant restricted or limited from participating in any physical activity?
If yes, please state below.
Your answer
Please provide a record of past medical treatment, if any, including injures or surgeries.
Your answer
Participant has the following health conditions/allergies/dietary restrictions (food or medication)
Allergies:
Your answer
Emergency Contact (non-parent)
Your answer
Relationship:
Your answer
Phone:
Your answer
Cell:
Your answer
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:
Your answer
Date:
Your answer
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:
Your answer
Date:
Your answer
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