Girl Scouts Western Pennsylvania Camp Health History Form (Page 2 of 2) in pdf

HEALTH HISTORY FORM

Please list the date of camper’s last Tetanus vaccine (This is required for all attendees):

Month________ Year________

Please initial next to one of the following:

________ I attest that all of the camp attendee’s immunizations (as required for school) are up to date.

________ Camp attendee has not received immunizations for religious or other reasons. (Please contact the Camp

Director to obtain and complete an immunization waiver. The waiver is required for camp attendance.)

CAMPER MEDICATIONS

Please list all medications including prescription, over the counter, and as needed medications.

Medication

Dosage

Time taken (Check all that apply):

Brkfast

Lunch

Dinner

Bedtime

Reason for taking and special instructions

Medication

Dosage

Time taken (Check all that apply):

Brkfast

Lunch

Dinner

Bedtime

Reason for taking and special instructions

Medication

Dosage

Time taken (Check all that apply):

Brkfast

Lunch

Dinner

Bedtime

Reason for taking and special instructions

Medication

Dosage

Time taken (Check all that apply):

Brkfast

Lunch

Dinner

Bedtime

Reason for taking and special instructions

Medication

Dosage

Time taken (Check all that apply):

Brkfast

Lunch

Dinner

Bedtime

Reason for taking and special instructions

IMPORTANT – The following must be complete for camp attendance.

Permission to Provide Necessary Treatment or Emergency Care: I hereby give my permission to medical personnel

selected by Girl Scouts Western Pennsylvania to order x-rays, routine tests, treatment; to release any records necessary

for insurance purposes; and to provide or arrange necessary related transportation for me or my child. In the event that I

cannot be reached in an emergency, I hereby give my permission to the physician selected by Girl Scouts Western

Pennsylvania to secure and administer treatment, including hospitalization for the person named above. This health

history form is complete to the best of my knowledge, and the person herein described has permission to engage in all

program activities, except as noted. This completed form may be photocopied.

Parent/Guardian Signature

Date

Girl Scouts Western Pennsylvania Camp Health History Form Page 2

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