Fillable 20__- 20__ HEALTH INFORMATION AND RELEASE FORM (Girl Scouts of Greater Los Angeles)

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20__- 20__ HEALTH INFORMATION AND RELEASE FORM (Girl Scouts of Greater Los Angeles)

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20__- 20__
Updated June 2020
HEALTH INFORMATION AND RELEASE FORM
To be completed and reviewed annually by parent/caregiver. This form is to be kept with the troop/group
records and accompany the troop/group leader on all troop/group activities. It is designed to provide the
troop/group leader with the information needed to access medical care for your girl. It should be reviewed and
updated (as needed) when information changes.
COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. As with any
social activity, participation in Girl Scouts could present the risk of contracting COVID-19. While GSGLA takes
every safety and preventative precaution, GSGLA can in no way warrant that COVID-19 infection will not occur
through participation in GSGLA programs
Name: Date of Birth: Phone #:
Address:
City: State: Zip: Troop/Group #:
PART I: PARENT/CAREGIVER INFORMATION AND RELEASE
The above Girl Scout is under the custodial care of:
Both Parents Mother only Father only _____ Caregiver(s) (specify) _____________________
Mother/Caregiver Name:
Address (if different than girl):
Phone (day): Phone (evening):
Cell Phone: Email:
Father/Caregiver Name:
Address (if different than girl):
Phone (day): Phone (evening):
Cell Phone: Email:
PART II: EMERGENCY CONTACT AND RELEASE INFORMATION
In the event that I cannot be reached in an emergency, the following are authorized to act in my behalf:
Name: Relationship to Girl:
Cell Phone: Other Phone:
Name: Relationship to Girl:
Cell Phone: Other Phone:
PART III: HEALTH CARE INFORMATION:
Physician’s Name: Phone:
Dentist’s Name: Phone:
Is the girl covered by family medical/hospital insurance? Yes No
If so, carrier or plan name: Policy or Group #:
Name of insured: Relationship to girl:
20__- 20__
Updated June 2020
MEDICAL HISTORY (check those that apply)
Asthma Provoked
by:
_________________
Has Prescribed
Inhaler
Diabetes
Epilepsy
Fainting
Lactose Intolerant
Medical Tags/Devices
Nosebleeds
Seizures
Skin Condition
Hearing Impairment
Vision Impairment
Wears Contact Lenses
Additional health information including disabilities and/or special needs (medical, physical, emotional, etc...)
Please Specify:
IMMUNIZATION HISTORY (check those that apply)
Date: __________________
Immunization Records Are Up-To-Date
N/A
PART IV: MEDICATION (For day outings or overnights only.)
Over-the-counter medication, such as sunscreen, insect repellent, pain relievers, antibiotic ointment, antiseptic wipes,
etc. cannot be administered by Girl Scout Leaders unless the Over-the-Counter (OTC) Form is completed and signed by
a parent/caregiver. Also, if a Girl Scout is required to carry or regularly receive prescription or over-the-counter
medications (including Epi-Pens and Inhalers) that will be provided by a parent/caregiver, that must be noted on the
Provided Prescription and/or Provided OTC Medication Form as well.
Permission Granted (see attached OTC/Rx Permission Form)
Permission Not Granted (no form attached)
PART V: EMERGENCY MEDICAL AUTHORIZATION: In the event of an emergency, every effort will be made to contact
a parent/caregiver or emergency contact. I hereby give authorization to Girl Scouts of Greater Los Angeles to seek
treatment for my child and/or dependent minor by a licensed physician pursuant to California Family Code Section 6910
and California Civil Code Section 25.8. I know of no reason(s) why my girl may not participate in prescribed activities except
as noted on this Health History Form. If permission for emergency medical treatment is not given, I will prepare a signed
statement providing the reason, a release of liability, and alternate instructions and attach to this form.
Signature of Parent/Caregiver: Date:
Signature of Parent/Caregiver: Date:
I do not consent to the care or treatment set forth herein. Describe in detail what is/is not allowed/permitted:
ALLERGY HISTORY (check those that apply)
Animals
Chlorine (pool)
Hay Fever
Other __________
Insect Stings
_______________
Plants/Pollen
_____________
Medicine/Drugs
_____________________
FOOD: Please list all that we should be aware of.
Indicate if
Intolerant ( I ) or Allergic ( A ).
Ex.
Strawberries
A
, Milk
I
Corn ________________
Dairy _______________
Eggs ________________
Fish _________________
Food Coloring _________
Gluten/Wheat ___________
Peanuts ________________
Shellfish _______________
Soy ___________________
Tree nuts _______________
Other Food Allergies Aware Of:
Fruits/Veggies __________________________
______________________________________
______________________________________
Inhaler or Epinephrine Used (will add to Medicine form)
Dietary special needs _________________
If any allergy box was checked, please indicate what the reaction is. Such as: strawberries/rash, milk/cramps, etc.
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20__- 20__ HEALTH INFORMATION AND RELEASE FORM (Girl Scouts of Greater Los Angeles)

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Completed 25 July 2021

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