AHG Adult Health & Medical Form 2026-27

Adult Health and Medical Form

Troop Number FL0941

Each year, AHG Girl and Adult Members must complete a new Health and Medical Form to be kept on file at the Troop level.
Member Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Weight
Height
Street Address
City, State Zip
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contacts
Contact 1 Name
Contact 1 Relationship
Contact 1 Phone Number
Format: (000) 000-0000.
Contact 2 Name
Contact 2 Relationship
Contact 2 Phone Number
Format: (000) 000-0000.
Allergies

If applicable, please list all known allergies including medications, food, and environment.

Rows	Allergen	Reaction and management of reaction
Allergy #1
Allergy #2
Allergy #3
Allergy #4

General Health Information
Check all that apply, past or present, to this member's health history.
Additional notes about this member's behavior, physical, emotional or mental health needs pertinent to their participation in American Heritage Girls.
Medications
If medications of any type will be taken or needed during Troop meetings, events, activities or trips, please fill out the Request for Medication Administration Form.

Tetanus Immunization Policy

Tetanus Immunization Policy: AHG requires members to have Tetanus immunization within the last 10 years.
Select an option below regarding the member's tetanus immunization.
Date of tetanus immunization

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of individual or parent/guardian:
Immunizations

The following immunizations are recommended by AHG, Inc. but are not required.

Note this section is not required.

I give permission for full participation in American Heritage Girls programs, events and activities, subject to limitations noted herein. I know of no health reason(s), other than the information indicated in this form, why I or my daughter should not participate in any of the American Heritage Girls activities. Please check one:

In case of an emergency, I understand every effort will be made to contact me (or my next of kin). In the event that contact cannot be made, I hereby give my permission to the licensed health-care provider selected by my Troop or Charter Organization to secure proper treatment, including related transportation, hospitalization, anesthesia, surgery, or injections of medication for myself or my child, except as noted. I agree to the release of records necessary for treatment.
Additional notes:
Signature of individual or parent/guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Emergency Contacts