• Health & Permissions Form

  • Why This Form Matters

    Completing this health form fully and accurately helps us prepare to welcome your Girl Scout and give her the best possible experience. The details you share allow our staff to plan appropriately for medications, allergies, dietary needs, and any other considerations well before she arrives — not in the middle of check in when there are many other things happening. This information also shapes how we prepare and staff our events/camps.  Thank you for taking the time to complete this form thoughtfully — it's one of the most important ways you can help us keep your girl safe, comfortable, and ready for an unforgettable Girl Scout experience.

    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 3 weeks 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:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 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..

  • Session Start Date*
     - -

  • Pick up information - Name of person(s) authorized to pick up your child

    (at least 1 pick up person must be entered)

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Name of Person(s) NOT permitted to pick up your child

    (optional)

  • Do you have more events/camps to enter?*
  • Session Start Date
     - -

  • Pick up information - Name of person(s) authorized to pick up your child

    (at least 1 pick up person must be entered)

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Name of Person(s) NOT permitted to pick up your child

    (optional)

  • Session Start Date
     - -

  • Pick up information - Name of person(s) authorized to pick up your child

    (at least 1 pick up person must be entered)

  • Name of Person(s) NOT permitted to pick up your child

    (optional)

  • Health Information

  • Health Insurance Information - In case of accident or illness, personal insurance is primary, Girl Scout insurance is secondary.

  • Were any medical problems or complications noted in last health exam?*
  • Does the participant require any accommodations to fully participate in this program?*
  • Participant immunizations are up to date*

  • Allergies - List ALL allergies (including medications, food, bees, etc.), the type of reaction/severity, treatment and date of last reaction.

  • Does participant suffer from Anaphylaxis (a severe reaction marked by swelling of the throat and/or tongue, hives, and trouble breathing?
  • Do they carry an EpiPen?
  • Do they carry an inhaler?
  • Over the Counter (OTC) Medications & Dietary Restriction*
  • My child/participant takes prescription medication*

  • Prescription Medication 

    List any medications including dosage schedule and specific instructions for use. ALL prescriptions must be in the original container with the appropriate lable. If traveling, please provide extra written prescription(s) from the doctor with the generic name for all medications in case the original prescription is lost or a new one needs to be obtained.

  • I am the parent/legal guardian of {childsFull}, a registered Girl Scout who has a medical condition that requires that she take prescription medication. Throughout the course of the year, my child also may take over-the-counter medications as needed. Because I will be unable to be with them at the time they need to take prescription medication, I give troop co-leader, authorized volunteer, GSDH council staff permission to administer the medications noted to my child or legal ward according to the instructions of their medical provider. 

  • Date
     - -

  • 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.

  • 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.

  • 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.

  • 4. 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 for field trips, including transportation 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. 

  • Date
     - -
  • Should be Empty: