Adult Consent Form for Small Craft Safety Training - Caloosa
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I give permission to certified adults to administer first aid and have aid given from a physician or hospital if the situation requires. It is my understanding that I am covered by Girl Scout Accident Insurance. I do not hold the troop, its leaders, or the Girl Scouts of Gulfcoast Florida, Inc. at fault in case of an accident.
I authorize the doctor or hospital personnel to provide emergency medical treatment and or anesthesia to be administered. This authorization includes, but is not limited to, any emergency treatment and/or surgical procedure(s) deemed necessary by the qualified personnel.
As with any social activity, participation in Girl Scouts could present the risk of contracting communicable illness, including COVID-19, and in no way can there be a guarantee that infection will not occur through participation in Girl Scout program activities. Adults will self-check for signs of communicable illness prior to attending Girl Scout activities, as they may be screened upon arrival. Any adults with a communicable disease, including fever, conjunctivitis, or lice, will not be able to participate until no signs of illness are present.
I have read and agree to the above statement.
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Yes
HEALTH HISTORY RECORD
This health history is to be completed and signed by each adult participant.
Name of Physician
*
Phone
*
Family Medical/Hospital Carrier
Policy or Group #
Date of last health examination
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Month
-
Day
Year
Date
Were there any complicating medical problems noted in the last health examination?
Please note any additional information regarding behavioral, physical, or emotional health.
HEALTH HISTORY
(Please check all that apply)
Diseases
Allergies
Specify any OTHER allergies
Chronic or Recurring Illness
Special Needs
LIST ANY MEDICATIONS - DOSAGE AND FREQUENCY:
EMERGENCY CONTACT INFORMATION
In case of emergency notify:
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First Name
Last Name
Relationship
*
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Read and Acknowledge
I have chosen to carry and administer my own medication such as: bronchial inhalers; EpiPen; or diabetes medication.
*
Yes
I fully understands that I am not allowed to give any medications that I have with me to any other person and will inform the person in charge of first aid when I have taken any of this medication myself.
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Yes
I will alert the Girl Scout council representative if I have tested positive for COVID-19, so that others may be informed. The council will inform families, keeping member health information strictly confidential.
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Yes
This health history is complete and accurate to the best of my knowledge. I affirm that my immunizations are up to date.
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Yes
This consent form serves as agreement for me to participate in all Girl Scout activities unless otherwise noted by me in writing.
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Yes
Signature
*
Submit
Should be Empty: