Fillable Girl Scouts Heart Of Central California, Girl Emergency Health Information Form printable pdf download

Girl Emergency Health Information

Girl Scouts Heart of Central California I 6601 Elvas Avenue Sacramento, CA 95819 I

This form is to be completed and signed by parents/guardians of the girl and updated annually.

Name _________________________________________________________________ Birthdate____________ Troop # _________________________

Address _________________________City _______________________Zip _________ Home phone (_____) ___________________________________

Family medical/hospital insurance carrier ____________________________________ Policy or Group No. ____________________________________

Parent/Guardian __________________________________________ Parent/Guardian ___________________________________________________

Day Phone (_____) _________________________________________ Day Phone (_____) __________________________________________________

Evening Phone (_____)______________________________________ Evening Phone (_____)_______________________________________________

Emergency Contacts (in the event parents cannot be reached)

Name____________________________________________________ Name_____________________________________________________________

Relationship ______________________________________________ Relationship _______________________________________________________

Day Phone (_____) _________________________________________ Day Phone (_____) __________________________________________________

Evening Phone (_____)______________________________________ Evening Phone (_____)_______________________________________________

Cell Phone (_____) _________________________________________ Cell Phone (_____) __________________________________________________

Email ____________________________________________________ Email _____________________________________________________________

The child may NOT be released to the following individuals:

Name____________________________________________________ Name_____________________________________________________________

Relationship ______________________________________________ Relationship _______________________________________________________

Phone (_____)_____________________________________________ Phone (_____)______________________________________________________

Does the participant have any allergies, special needs or a special diet we should be aware of? □ Yes □ No

If Yes, please explain:___________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

(For example, please list all medications, plants, animals, etc. that the participant is allergic to and/or indicate whether the participant has special

needs like asthma or diabetes.)

Please provide any information in relation to the care of the participant that would be useful to the adult in charge. Also indicate any activities to be

encouraged or restricted. _______________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

The above information is correct to the best of my knowledge, and my daughter has my permission to engage in all activities, except as noted. I

hereby authorize Girl Scouts Heart of Central California, through the adult person(s) caring for my daughter, to order emergency X-rays, anesthetic,

medical or surgical diagnosis or treatment and hospital care as deemed advisable by a licensed physician. It is understood that every reasonable

effort will be made to contact me or the person noted above before taking this action. I understand that this permission is given in advance of need

for any diagnosis, treatment, or hospitalization. This authorization shall remain effective throughout the entirety of the individual’s membership in the

Girl Scouts Heart of Central California.

I agree to inform a troop or activity leader of any changes in the above information. For example, if a Girl Scout later develops an allergy or contagious

disease or is no longer allowed to participate in a particular activity, the parent or individual must inform the troop or activity leader to ensure the

safety of both the individual and those around her.

_______________________________________________________

_____________________________________________________________

Date

Signature of parent/guardian

_______________________________________________________

_____________________________________________________________

Updated

Signature of parent/guardian

_______________________________________________________

_____________________________________________________________

Updated