Girl Scouts Of Kansas Heartland Health History And Authorization Form
ADVERTISEMENT
1
2
3Girl Scouts of Kansas Heartland
Health History and Authorization Form
Section A and B: (personal information, health history, authorization) is to be completed for all Girl Scout activities and turned
in to a troop volunteer or program staff. Complete information is essential to provide the care the participant may need. This
form is confidential and will be stored in a secure location. The Health History and Authorization Form must be reviewed
annually. When changes are necessary, complete a new form.
Minor
Adult
Section A)
Personal Information:
Please type or write clearly and legibly.
Participant’s Name:
Date of Birth:
(Last, First, Middle Initial)
(XX/XX/XXXX)
Address:
City:
St:
Zip:
If minor, Parent or Guardian:
Phone:
Alternate Phone:
If minor, Parent or Guardian:
Phone:
Alternate Phone:
Emergency Contact Information:
For minors, alternate contact in case parent/guardian cannot be reached.
Emergency Contact:
Relationship:
Phone:
Alternate Phone:
Health Insurance Information:
Family insurance is primary insurance in case of accident or illness; Girl Scout insurance is secondary.
Family Physician:
Hospital Preference:
Policy Holder's Name:
Policy Number:
Insurance Company Name:
Group Number:
Insurance Company Address:
Insurance Company Phone:
Section B) Health History:
Allergies: Please list all allergies, the type of reaction and its severity, treatment and date of last reaction. Include allergies to
medications, food, bees, animals, plants, etc.
Allergies
Reaction/ Severity
Treatment
Date of last Reaction
1.
2.
3.
Does the participant suffer from Anaphylaxis?
Yes
No
*Anaphylaxis is a severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing.
Does the participant carry an Epipen?
Yes
No
Does the participant carry an inhaler?
Yes
No
Medical Conditions (including any precautions or restrictions on activities)
Name of Condition
Effects
1.
2.
3.
4.
4/2016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business