2026 Girl Medical History

2026 Girl Medical History
Campers Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Age*
Parent/Guardian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In Case of Emergency
Contact # 1 Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Contact #2 Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Health History
Frequent Ear InfectionsHeart DiseaseConvulsionsDiabetesBleeding/ Clotting DisorderHay FeverIvy PoisoningInsect StingsPenicillinChicken PoxMeaslesGerman MeaslesMumpsAsthmaCovid 19
Has she begun menstruation*
Does she have history of bed wetting*
Please bring all medication to camp in original bottles/container
Current Medications
Other Drug Allergies
Operations or Serious Illness
Anything else Doctor should know.
Name of Family Physician*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Authorization to Treat Minor
Campers name*

First NameLast Name
GIRL SCOUTS OF EASTERN SOUTH CAROLINA COUNCIL

AUTHORIZATION TO TREAT MINOR

I/We, the undersigned, am either a custodial parent or guardian of above named, a minor (the “Minor”), and do hereby authorize the adult leaders and agents of the Girl Scouts of Eastern South Carolina (collectively the "Authorized Persons") to consent to any X-ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care for the Minor under the general or special supervision and upon the advice of or to be rendered by a licensed physician, and to consent to any X-ray, examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care for the Minor by a licensed dentist. Each of the authorized persons may exercise the authority granted hereby individually and without the knowledge, consent or joint action of any other of the authorized persons. It is understood that an effort shall be made to contact the parent or guardian prior to rendering treatment to the Minor, but that any of the above treatments will not be withheld if the parent or guardian cannot be reached.
I have read the above statement and agree. Parent Guardian Signaute*
Authorization To Attend Camp
Campers Name*

First NameLast Name
I/We give permission for above named to participate in all camp activities, with the exception of those restrictions indicated on the reverse side.
Restrictions set by parent/guardion
Signature*
Authorization To Transport Minor
Campers Name*

First NameLast Name
I/We hereby give permission for above named to ride in a vehicle driven by a licensed adult driver, or, in an emergency, a minor licensed driver, in a vehicle which has at least minimum liability insurance as required by the State of South Carolina, for Girl Scout camp activities
Parent/Guardian Signature*
Anything else you would like us to know.
Should be Empty:

2026 Girl Medical History

In Case of Emergency

Health History

Authorization to Treat Minor

Authorization To Attend Camp

Authorization To Transport Minor