Fill - Free fillable PARENT/GUARDIAN PERMISSION FOR GIRL SCOUT ACTIVITIES TP105 (Girl Scouts North Carolina Coastal Pines) PDF form

TP105/07‐20

GirlScouts–NorthCarolinaCoastalPines

6901PinecrestRoad,Raleigh,NC27613

(800)284‐4475or(919)782‐3021

Pleasecompletethisformandreturntoyourdaughter’stroopleader.Permission(s)andreleaseinformationis

neededbeforeyourdaughtercanparticipateinGirlScouttroopactivities.Pleaseprintlegibly.

Girl’sName Troop#

Address State Zip

Parent’s/Guardian’sName

Parent’s/Guardian’sPhone#( ) ‐ CellPhone#( ) ‐

EmergencyContactName/phone#

(*Someoneotherthantheparent/guardianwhowecancallinanemergency.)

ThispermissionisrequiredforallTroopactivities.Mydaughter/wardhasmypermissiontoparticipateinanytroop/group‐sanctionedor

GirlScouts‐NorthCarolinaCoastalPines‐sanctionedtrip,eventandactivitiesinpersonandon‐lineduringthe20 ‐20 membershipyear.

IunderstandthatIwillreceiveinformationgivingspecificdepartureandarrivaltimes,plannedactivities,contactpersons,andanyother

pertinentinformationpriortoanytriporevent.



COVID‐19isanextremelycontagiousvirusthatspreadseasilythroughperson‐to‐personcontact.Aswithanysocialactivity,

participationinin‐personGirlScoutsactivitiescouldpresenttheriskofcontractingCOVID‐19.WhileGSNCCPtakeseverysafety

andpreventativeprecaution,GSNCCPcaninnowaywarrantthatCOVID‐19in

fectionwillnotoccurthroughparticipationin

GSNCCPprogramsortroopactivities.PriortoanyGirlScoutprogramorac

tivity,discussproperphysicaldistancingbehaviorsand

health/safetyprotocolswithyourgirl.

Iagreethatpicturesorvideosofmydaughter/wardmaybeusedtopromotetheGirlScoutprogram.

Yes No

GSUSAprovidesactivityaccidentinsuranceassecondarycoveragetothefamily’sowninsurancecoverage.

CustodyType:(selectone)

BothParents Motheronly Fatheronly Other

Mychildmaybepickedupby:

*SignatureofParentorLegalGuardian Date/UpdatedDate

HEALTH HISTORY FOR GIRLS

NameofParticipant DateofBirth Age

NameofParticipant’sPhysician Telephone#( ) ‐

FamilyMedical/HospitalInsuranceCarrier Policy# Group#

Forthesafetyofyourchild,isthereaconditionthatyouwouldlikeustoknow(e.g.,nosebleed,emotionaldisturbances,menstrualcramps,

motionsickness,etc.)?

Isyourdaughtercurrentlyunderaphysician’scareforamedicalproblem?Ifso,explain:(optional)

Listanyallergiesyourdaughter/wardmayhave(i.e.,Pollen,insectstings,etc.)

Areyoucurrentwithyourimmunizations(checkone): YES NO Choosenottoimmunize.

AuthorizationforTreatment:IherebygivepermissiontothemedicalpersonnelselectedbytheGirlScoutadultinchargetoorderX‐rays,

routinetests

,treatment;toreleaseanyrecordsnecessaryforinsurancepurposes;andtoprovideorarrangenecessaryrelated

transportationformychild.IntheeventIcannotbere

achedinanemergency,Iherebygivepermissiontothephysicianselectedbythe

GirlScoutadultinchargetosecureandadministertreatment,includinghospitalization,forthepersonnamedab

ove.Thiscompletedform

maybephotocopiedforuseoff‐site.

Signatureofparent/guardianofminor Date/UpdatedDate

PARENT/GUARDIAN PERMISSION FOR GIRL SCOUT ACTIVITIES TP105

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TP105/07‐20

Girl’sName 

MEDICATION PERMISSION AND INSTRUCTIONS

Writtenparentalconsentisrequiredbeforeaminor(under18)GirlScoutmaybegivenanymedicationortreatmentofanykind.During

tripsoratevents,girlsmayneedmedicationforailmentssuchasheadaches,stomachaches,diarrhea,oralow‐gradefever.Theymight

needsunscreen,insectrepellentorChapstick.YouMU

STsendanyover‐the‐countermedicationyourdaug

htermayneedintheoriginal

bottle/package(INCLUDINGASPIRIN,TYLENOL,ETC.).Prescriptiondrugsmustbeintheoriginalbottle/packagewiththephysician’s

instructionsforadministeringthem.Putalldrugsintheiroriginalbottle/packageinaZiplocbagandlabelitwithyourdau

ghter’sname.

Medicationwillbeavailablefromtheadultinchargeoffirstaidandca

nbegivenasspecifiedbyinstructionsonthelabelforprescription

drugsorbywritteninstructionsfromparents/guardiansforover‐the‐counterdrugs.Completethemiddlepartofthisformwith

instructionsforoverthecou

nterdrugs..



Girlsmaykeepasthmasprays,epi‐pens,in

sectrepellent,orsunscreenwiththemiftheyknowhowtousethemwithpriorwritten

permissionfromparentsorfromtheadultinchargeoffirstaid.Allothermedicationmustbeturnedintotheadultinchargeoffirs

taid,

unlesswehaveanotesignedbyaphysicianstatingthatagirlmustkeepacertainmedicationwithher.



Itisthere

sponsibilityofthegirl/parenttomakesureallmedicationispickedupattheendofthetrip/event/camp.

Listallover‐the‐counterand/orprescriptionmedicationthatyourdaughterwillhaveatthistrip/event/camp.

Giveexactinstructionsforadministeringover‐the‐countermedications.*Wecannotadministerover‐the‐countermedicationwithout

writteninstructions.

MEDICATION

Prescribed INSTRUCTIONS INITIAL/DATE

 (originalcontainerwithdoctor’sorders) 

Overthecounter  INSTRUCTIONS  INITIAL/DATE

  



Medication/chemicaltreatmentsrecommendedbytheAmericanRedCross:

ThefollowingitemsarerecommendedbytheAmericanRedCrossastheappropriatetreatmentfortheseconditions.Initialeachtreatment

youwantyourdaughtertoreceiveifneeded.Thesemedicationsshouldbeavailableintrip/event/campfirstaidkits.Noothermedication

isavailableunlesssentwithyourdaughter.



 Poisoning SyrupofIpecac,ActivatedCharcoal‐administeredas

 directedbytheCarolinaPoisonControlCenter,1‐800‐848‐6946.

 Smallwounds,cuts, Antibioticointment

 animalortickbite,minorburn

 PoisonIvy TopicalantihistaminesuchasCaladrylorBenadryl

 Marinelifestings Bakingsodaandsaltwater

 Sunburn Aloegel

 Insectbites TopicalantihistaminesuchasBenadryl



Igivemypermissionformydaughter/ward,  ,totakethemedicationslistedaboveand,ifneeded,

tohaveanyofthetreatmentsIhaveinitialed.

SignatureofParentorLegalGuardian

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PARENTGUARDIAN PERMISSION FOR GIRL SCOUT ACTIVITIES TP105 (Girl Scouts North Carolina Coastal Pines)

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