Adult Activity Waiver – Emergency Information
This optional form may be requested by event coordinators when hosting adult participants for travel or rigorous physical
activities. The Adult Health History form VP-87 is no longer required.
This form is used in all situations except for Resident Camp where an adult volunteer or paid staff member must submit the
Resident Camp Health Form.
Name of activity:
Date:
I, ,the undersigned, attest and verify that I am mentally and physically fit and able to
participate in this event/activity and acknowledge that I am aware of the inherent risks in participating in this event/activity.
I understand that as a registered adult volunteer of Girl Scouts of Eastern Missouri I am covered under the Girl Scout Activity
insurance when participating in a Girl Scout event.
____ I waive this opportunity to disclose my health history.
____ I choose to disclose the following health information, e.g. insect or food allergies, that may be helpful for a first aider
or event coordinator to know about me:
Medical Information to Relay to EMS
Are you currently taking prescription medications? Yes No
Either of the following used? Inhaler EpiPen
Please provide any current medical information or chronic conditions that should be relayed to EMS in case of emergency.
Signature: Date:
Print Name:
Troop, District, Neighborhood (if applicable):
Emergency Contact: Relationship: Phone:
VP-84
KD/sa
