DRAFT Health and Permission Form

Health & Permissions Form
Need to submit an updated Health & Permission Form for yearly troop records, a troop event or service unit event?
Stop - do not submit this online form.

Print and complete a paper Health & Permission Form and submit directly to your troop leadership or specific event contact.

Need to submit a Health & Permission Form for a specific Dakota Horizon's council camp or event?
Complete and submit this online form at least 6 days prior to the session date.

Within 5 days of your session date, a completed paper Health & Permission Form will be required to turn in at camp or event check in.
PRINTABLE HEALTH & PERMISSION FORM
This form is for:*

Girl Scout youth - to be completed and signed by parent/guardianAdult - self complete
Participant Full Name*

First NameLast Name
Age*
Date of Birth

MonthDayYear
Parent/Guardian Name*

First NameLast Name
Email (parent/guardian or adult self)*
example@example.com
Phone (parent/guardian or adult self)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (First and Last Name)*
Phone (emergency contact)*
Relationship to Participant*
Additional Emergency Contact (First and Last Name)
Phone (emergency contact)
Relationship to Participant

Participation in Dakota Horizon's Council Activities

Enter event or camp details below for your registered participant. Up to 3 event or camp sessions can be entered on one form submission..
1. Camp or Event Name*
Session Start Date*

MonthDayYear
Date
Location*
Pick up information - Name of person(s) authorized to pick up your child

(at least 1 pick up person must be entered)
Name (First and Last)*
Phone Number*
Relationship to child*
Name (First and Last)
Phone Number
Relationship to child
Name of Person(s) NOT permitted to pick up your child

(optional)
Name (First and Last)
Relationship to child
Name (First and Last)
Relationship to child
Do you have more events/camps to enter?*

YesNo
2. Camp or Event Name
Session Start Date

MonthDayYear
Date
Location
Pick up information - Name of person(s) authorized to pick up your child

(at least 1 pick up person must be entered)
Name (First and Last)
Phone Number
Relationship to child
Name (First and Last)
Phone Number
Relationship to child
Name of Person(s) NOT permitted to pick up your child

(optional)
Name (First and Last)
Relationship to child
Name (First and Last)
Relationship to child
3. Camp or Event Name
Session Start Date

MonthDayYear
Date
Location
Pick up information - Name of person(s) authorized to pick up your child

(at least 1 pick up person must be entered)
Name (First and Last)
Phone
Relationship to child
Name (First and Last)
Phone
Relationship to child
Name of Person(s) NOT permitted to pick up your child

(optional)
Name (First and Last)
Relationship to child
Name (First and Last)
Relationship to child

1. I understand that I am responsible for ensuring my child is picked up on time from meetings and activities. I understand that neither the volunteer nor Girl Scouts is responsible for driving them home or walking with them.
1. Initials (Pick Up)*
2. I am the parent or guardian having legal custody of {childsFull}. I authorize all medical, surgical, diagnostic, and hospital care or procedures which may be performed or prescribed for my child by a licensed physician or hospital, when efforts to contact me are unsuccessful and when deemed immediately necessary or advisable by the physician to safeguard my child's health. I waive my right of informed consent to such treatment. I will take full responsibility for all charges that occur. Girl Scout insurance is secondary to your primary insurance.
2. Initials (Medical)*
3. I know of no reason(s), other than the information indicated on this form, why my child should not participate in activities except as noted.
2. Initials (Activities)*
4. For Troop - Throughout the year, there will be meetings and field trips held outside the normal meeting space. Your signature will give permission for all of our group's local activities, including any field trips of one day or less. If the leader does not hear from you prior to the event date, she/he will assume based on your signature below that your child has your permission to participate.
4. Initials (Troop Activities)*
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 or my child's participation in activities. My signature on this form evidencing my release of the council, its agents and employees.*

Clear
Signature of Parent/Guardian of Child Participant, or of Adult Participant Named on Form
Date

MonthDayYear
Date
Should be Empty:

Health & Permissions Form

Health Information