AHG Troop FL0941 Registration Forms

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City, State Zip
Parent/Guardian Name(s)
Full Name
Phone Number(s)
Format: (000) 000-0000.
Emergency Contacts
Contact 1 Name
Full Name
Contact 1 Relationship
Contact 1 Phone Number
Format: (000) 000-0000.
Contact 2 Name
Full 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.

Meeting Dates
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.Type a question

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:
Troop FL 0941 Meeting Permission Slip
This form is valid for the entire Program Year.
If any information changes, parent/guardian(s) can make updates at any time.

Meetings to occur the following Mondays from 4p-5:30 EST at 8000 Bee Ridge Road Sarasota, FL.

Dates: 8/31, 9/14, 10/5, 11/2, 12/7, 1/11, 2/8, 3/8, 4/12
Girl Member can be released to the following people:
As the parent/guardian I authorize my daughter to participate in Troop Meetings for the duration of the Program Year. I understand Troop Meetings may be held virtually when necessary.
Parent/guardian signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Troop FL 0941 Meeting Permission Slip