Health and Permission Card
Health and Permission Card
Completed by parent / guardian and reviewed with physician at time of examination
Name ( Last , First , Initial ) Parent or Guardian Date of Birth Age
Address City State Zip Code
( Area Code ) Phone Cell Phone E-mail Address
Emergency Contact |
Emergency Phone |
Troop # |
|
|
___ ___ ___ ___ ___ |
HEALTH HISTORY ( Check those that apply )
Allergies ( Specify )
□ Animals ____________________
□ Foods ______________________
□ Hay Fever ___________________
□ Insect Stings _________________
□ Medicine / Drugs ( list ) __________ _____________________________ _____________________________
□ Carries Epi-pen ? For __________
□ Plants ______________________
Chronic or Recurring Illness
□ Ear Infections
□ Heart Defect / Diseases
□ Seizures
□ Bleeding / Clotting Disorders
□ Asthma
□ Hypertension
□ Diabetes
□ Musculoskeletal Disorder
□ Other ( Specify ) _______________________
□ Pollen ______________________ Year of last tetanus booster ________________________________________________ Is applicant ’ s immunization record up to date ? YES or NO Date of last health examination _____________________________________________ List daily medications ____________________________________________________ _______________________________________________________________________
Girl Scouts — Dakota Horizons
1101 S Marion Rd , Sioux Falls , SD 57106 605-336-2978 or 800-666-2141 Fax 605-336-6841 www . gsdakotahorizons . org
Other Health Conditions
□ Bed Wetting
□ Constipation
□ Menstrual Cramps
□ Motion Sickness
□ Nosebleeds
□ Sleep Disturbances
□ Emotional Disturbances
□ Fainting
□ Hearing Impairment
□ Sickle Cell Trait or Disease
□ Special Dietary Needs
□ Wears Glasses or Contact Lenses
□ Other ( Specify ) ________________________________ ________________________________ ________________________________
__________________________________ Please explain any items that are checked above . Indicate any information useful to the adult in charge in relation to any of these health conditions . Also , indicate any activities to be restricted . ______________________________________________________________
______________________________________________________________________________________________________________ _
Doctor ________________________________________ Preferred Hospital __________________________ Insurance Provider _____________________________ Policy Number _____________________________
PARENT / GUARDIAN AUTHORIZATION : This health history is complete and accurate , and the person herein described has my permission to engage in all prescribed activities , except as noted by me . In the event I cannot be reached in an EMERGENCY , I hereby give permission to the physician named above , or if not available , to the physician selected by the adult in charge , to hospitalize , secure proper treatment for and to order injection , anesthesia or surgery for my child as named above . Please update and sign annually .
DATE __________________________________ PARENT / GUARDIAN SIGNATURE _______________________________________________________________
DATE __________________________________
PARENT / GUARDIAN SIGNATURE _______________________________________________________________
~ HOLD HARMLESS AGREEMENT ~ I hereby release and hold harmless Girl Scouts — Dakota Horizons from any and all claims or liability arising from , out of or associated with my child ’ s participation in the activity ( s ) listed on this card . My signature should be placed next to each event on the back of this form evidencing my release of the Council , its agents and employees as to that specific activity .
Parent / Guardian Signature __________________________________________________________________________ Date ______________________________________________________________ ( OVER )
Revised 10 / 15 / 12
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