© Girlguiding 2014 Health Information 1 of 3
Part I – to be completed by the event coordinator or first aider
Name of event/activity
Start date End date
Person responsible for first aid at the event
Part II - to be completed by:
parents* of participants (including children of volunteers) under the age of 16
members of The Senior Section aged 16 and over
adult volunteers attending a girl event (if adults wish to keep their health information confidential they may
carry it in a sealed envelope that will be opened only in the case of an emergency).
NOTE: Over-16s attending a 16+ event are NOT required to complete this form.
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
© Girlguiding 2014 Health Information 2 of 3
General health information
Does the participant have any allergies?
No
Yes (details –
severity,
EpiPen
information
etc)
Does the participant have any illnesses or disabilities relevant to this event/activity?
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
first 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)
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© Girlguiding 2014 Health Information 3 of 3
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
How do they know the participant? How do they know the participant?
Consent
I authorise the Leaders and first 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
Arrangement for return of form
* Where the terms ‘parent’ and ‘daughter’ are used, they refer to any adult with parental responsibility, and their ward.
Please provide details of a person who will be
contactable at all times during the event/activity.
click to sign
signature
click to edit
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