Explain any specific needs or accommodations required:
Explain any known behavioral and/or emotional problems:
Explain any psychiatric counseling or hospitalization:
Explain any operations or serious injuries:
Explain any disabilities or chronic or recurring illnesses:
Explain any activities that are discouraged or limited by your child’s physician:
Explain any dietary modifications:
Has menstruation begun? Yes No If not, does she know what it is? Yes No If yes, is her menstrual history normal? Yes No
Since her last health exam, has your child had:
Explain “yes” answers. Provide details and dates.
A serious injury requiring medical attention?
An illness lasting longer than one week?
An in-patient hospital or emergency room treatment?
Restrictions from participating in any activities?
Date of Last Health Exam: Current Height: Current Weight:
IMMUNIZATION HISTORY
Are all immunizations current? Yes No If not, state reason(s): DTP or DT (Tetanus) Date:
MEDICATION INFORMATION
Are any prescription medications being taken? Yes No Are any of the following used? Inhaler EpiPen
My child may be given: Aspirin Benadryl Ibuprofen Neosporin Tylenol None
MEDICAL CARE AND INSURANCE INFORMATION
Physician: Phone: Dentist/Orthodontist: Phone:
Preferred Medical Facility: Address:
Insurance Company: Policy #: Policy Holder:
Company Address: City: State: Zip:
AUTHORIZATION FOR MEDICAL CARE
This health history is correct so far as I know. The person herein described has permission to engage in all activities except as noted. I
hereby give permission to the First-Aider or Adult-In-Charge to provide routine health care and witness prescribed medications. I
consent for my child to receive such medical treatment and/or surgical procedures as are deemed necessary in the event of an
emergency and to assume liability for any medical expenses involved. This authorization extends to my child’s participation in any
activity sponsored by Girl Scouts of the USA, Girl Scouts Nation’s Capital, or individual units. Should a medical emergency arise during
my child’s participation in a Girl Scout-sponsored activity, I understand that reasonable efforts will be made to contact me or my
designated alternate at the phone numbers I have given. If it is believed my child’s life or health may be adversely affected by the delay
that an attempt to contact me or my designated alternate would cause, I consent to the administration of medical treatment and/or
surgical procedure deemed necessary by the medical doctor and/or medical facility and the immediate administration of life -sustaining
measures deemed necessary under the circumstances. This completed form may be photocopied.
Signature: Date:
* If for any reason you cannot sign this form, attach a written statement to this form. The statement must be signed for attendance/participation.
This form is available online at http://www.gscnc.org/troop_leader_forms.html
Last Updated: February 2014
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