© Girlguiding 2018 Health Information for International Travel 1 of 4
Part I – to be completed by the event coordinator or rst aider
Name of event/activity
Country(ies) to be visited
Start date End date
Person responsible for rst aid
Part II - to be completed by:
parents* of members under the age of 16
members of The Senior Section aged 16 and over
adult volunteers (if adults wish to keep their health information condential they may carry it in a sealed
envelope that will be opened only in the case of an emergency).
Participant details
Surname Membership number
First name Date of birth
Address
Date of last anti-tetanus injection
GP’s name
GP’s telephone number
GP surgery name or GP’s address
Medication
The following medication will be available at the event. Please tick to indicate which may be given to your
daughter if required (girls under 16 only).
Health Information for
International Travel
© Girlguiding 2018 Health Information for International Travel 2 of 4
Health information
Does the participant have any allergies?
No
Yes (details
severity,
EpiPen
information
etc)
Do any pre-existing medical conditions or disabilities affect the participant?
No
Yes (details)
Is the participant currently taking medication?
No
Yes (details
including
reason
for its use)
Does the participant self-medicate? No Yes
Medication: Please label young members’ medication with their name and provide clear instructions for its
use (whether or not she self-medicates, dosage etc).
Inhalers and EpiPens: Ensure a spare, clearly labelled inhaler or EpiPen is brought to event, to be held by
rst aider.
Is the participant currently receiving medical treatment?
No
Yes (details
including
hospital
name and
address)
Is there any further information the event team should have regarding the participant’s health and well-being?
No
Yes (details)
Continues on next page
© Girlguiding 2018 Health Information for International Travel 3 of 4
Health information (continued)
Check with a medical professional which immunisations are necessary for your trip and provide details of when
these were/are due to be received (including anti-malaria treatment)
Immunisation: Date:
Has the participant visited a doctor for any reason at all in the last six months?
No
Yes (details
severity,
EpiPen
information
etc)
I conrm that is t to take part in this trip.
Emergency contacts
Please provide details of a person who will be
contactable at all times during the event/activity.
Name Name
Telephone 1 Telephone 1
Telephone 2 Telephone 2
Address Address
Email Email
How do they know the participant? How do they know the participant?
Consent
I authorise the leaders and rst aiders at this event to give permission for my child to receive any emergency dental,
medical or surgical treatment, including anaesthetic, as considered necessary by the medical authorities present.
Parent’s signature Date
Parent’s name
Information given is true and correct at the time of signature. Any changes to 's medical
situation will be communicated to the event coordinator and travel insurer.
Participant’s signature (if over 16) Date
Participant’s name
Note: Some medical conditions require a doctors note to conrm tness to travel. See the guidance notes
at the end of this form for futher information.
Please provide details of a person who will be
contactable at all times during the event/activity.
© Girlguiding 2018 Health Information for International Travel 4 of 4
Guidance notes for completing this form
This form must be completed in order for young members to take part in an international event.
• Theformshouldbecompletedattheearliestopportunity,beforearrangingorpayingfortravel.
• Anychangestothehealthoftheparticipantbetweencompletingthisformandthestartofthetripmustbe
communicatedtotheEventCoordinatorand,ifappropriate,thetravelinsurancecompany.
• Pleaseprovidedetailedinformationrelatingtoanyillnesses,medicationortreatmentincaseofamedical
emergency.
• Iftheparticipant’sbeliefsmeantherearesometreatmentstheywillnotconsentto,pleaseensurethese
areclearlycommunicatedtotheEventCoordinator,andprovidedetailsonthisformunder‘furtherinformation
regardingtheparticipant’shealthandwell-being’.
Travel insurance
IfusingGirlguiding’sinsurer,Unity,fortravelinsurance,participantswithanyofthefollowing
medicalconditionsarerequiredtocompleteaMedicalHealthQuestionnaire(whichisavailableat
guidinginsurance.co.uk/pdfs/travel_medical_questionnaire.pdf):
• stroke,heartconditionorcirculatorydisorder
• cancerofanytype
• mental,nervous,depressiveorstress-relatedcondition
• slippeddisc,otherspinaldisorder
• diabetes,hernia,rheumaticorarthriticcondition
• anyotherillnessorinjurywhichrequiresinpatienttreatmentorinvestigation
Pleasebeawarethattheremaybeachargeforobtainingadoctor’scerticate.
Insurance claims
Intheeventofatravelinsuranceclaimarisingfromapre-existingmedicalcondition,theinsurerwillrequire
writtenevidencefromtheclaimant’sdoctorconrmingtheclaimantwasttotravel.
Further information is available at guidinginsurance.co.uk
What will you do with my data?
It’ssimple.Weneedtheinformationyousharewithustorunourexcitingactivities
andtosatisfyourlegalresponsibilities.We’llkeepitsafeforaslongasyourdaughterisanactivemember.
Wepromisewe’llonlyshareyourinformationif:
you ask us to
thelawrequiresus
inordertocomplywithourpoliciessoyourdaughtercanenjoyanactivitysafely
wecarryoutmarketresearch
it’sinthepublicinterest.
Don’tworry–we’llneversellyourdataorshareitforanyotherreason.
Girlguidingistheregistereddatacontroller*forallourmembers’personalinformation,bothintheUK
andaroundtheworld.
Wanttondoutmoreabouthowweuseyourinformation–andyourrights?
Visit girlguiding.org.uk/privacy-policy
*Theorganisationthatmanagesandlooksafteryourdata
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