Girl Scouts of
Name______________________ Date of Birth___________ Age_________
Address_________________________________________________________
Name of
Parent/Guardian___________________________________________
Phone (
) ___________________
Cell Phone (
)__________________
Business Address of Parent/Guardian
_________________________________
Phone ( )
____________________
Child’s Physician
_________________________________________________
Phone ( )_______________________
Family Medical Insurance Carrier
____________________________________
Policy or Group Number_______________________ Phone ( )__________
Date of daughter’s last medical
exam_________________________________
Were any complicating medical problems noted in your
daughter’s last exam?___
Is your daughter currently under a physician’s care
for a medical problem?___
Since her last exam, has your daughter had:
a serious injury requiring
medical attention?_____
an illness lasting longer than
one week? _____
a surgical operation or
fracture?____
medication, prescribed by a physician,
to be taken on a regular basis?___
treatment in a hospital as an in-patient,
or in the emergency room?___
Is your daughter restricted from participating in
any school physical education activity?___
Please explain all “yes” answers below:
A written statement from your daughter’s physician,
granting her permission to participate in strenuous activity such as water
sports, horseback riding, skiing, hiking, or noncontact
sports such as track, tennis or gymnastics is required if: 1) your
daughter has not had a health examination in the previous three years, or 2) you
have indicated a “yes” reply to any of the above questions.
PART I Illness and injuries (Check those that apply)
Chronic or recurring illness:
___ Asthma ___
Epilepsy ___Convulsions ___ Heart disease
___Diabetes ___Kidney
Disease ___Ear Infection ___Other (Specify)
Other(details):
PART II Allergies:
___Animals ___Medicines ____ Food ___ Plants
___Hayfever ___ Pollen ____ Insect stings ___ Other
Specify all allergens for each check mark above in
detail:
PART III Immunizations
Immunization Year
series completed Year
of last Booster
DTP
Diptheria
Tetanus
Measles
Mumps
Oral Polio
Rubella
Tuberculin Test Type__________________ Year last given
__________ Results__________
PART IV Other health Conditions (Check those that apply)
___Bed wetting ___
Constipation ___Emotional
disorders
___ Wears contact lenses ___Hearing impairment ___ Menstrual cramps
___ Motion sickness ___ Nosebleeds ___ Wears glasses
___ Sickle cell anemia ___Special dietary regimen ___Other (specify)
Explain “yes” to answers to the above PART IV.
Indicate any information useful to the adult in charge in relation to any
health condition. Also indicate any
activities to be encouraged or discouraged. If using additional pages please so
indicate_______________________.
I know of no reason(s), other that the
information indicated on this form, why my daughter should not participate in
prescribed activities, except as noted by the physician.
Signature of Parent/Legal Guardian________________________ Date_______________
If the emergency contacts listed on the other
side of this form are not available, I authorize my daughter’s troop leader to
act in my behalf for any injury necessitating treatment by a physician or in a
hospital.
Signature or Parent/Legal
Guardian_________________________ Date______________