GirlScouts–NorthCarolinaCoastalPines
6901PinecrestRoad,Raleigh,NC27613
TP106/08‐2016
ADULT HEALTH HISTORY TP106
Name________________________________ Male Female Phone (H)_____________ (C) ___________Birthdate______
Address________________________________________________ City __________________ State___________ Zip__________
IN CASE OF EMERGENCY, NOTIFY:
Name ___________________________________________________Phone (H) _______________ (W) ___________________
Address________________________________________________ City __________________ State___________ Zip__________
Can your emergency contact receive text messages? Yes No
Physician’s Name___________________ Physician’s Phone_____________________
Are there any health concerns the first aider/co-leader(s) should be aware of? Yes No If yes, explain_________
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Do you consider yourself to be physically and mentally able to participate in normal program activities? Yes No
If no, please explain_________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
If I am exposed to contagious disease in the three weeks prior to event/program, I will notify the director. To the best of
my knowledge, this health history is correct.
IN CASE OF EMERGENCY, I GIVE MY PERMISSION TO PERSONS REPRESENTING GIRL SCOUTS NORTH CAROLINA
COASTAL PINES TO SEE THAT I RECEIVE APPROPRIATE EMERGENCY MEDICAL OR SURGICAL TREATMENT, AND/OR
HOSPITALIZATION IF NECESSARY. IT IS UNDERSTOOD THAT EVERY EFFORT WILL BE MADE TO REACH THE PERSON
NAMED ABOVE.
Signature_________________________________________________ Date____________________________________________
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