Health History and Consent to Administer Medical Treatment

Health History and Consent to Administer Medical Treatment
This form must be completed annually and as changes occur by the child’s caregiver and returned to the troop leader and/or troop first-aider prior to attending the first troop meeting.

A copy of this form will automatically be emailed to your troop leader, please ensure you have entered the correct email address. Please note that Girl Scouts, Hornets' Nest Council does not retain a record of the information submitted in this form. This form can also be printed and submitted to your troop leader in person if you prefer.
Contact Information
I am filling the form out for:*

GirlAdult
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Caregiver 1 Name*

First NameLast Name
Caregiver 1 Email*
Caregiver 1 Cell Phone Number*

Area CodePhone Number
Caregiver 2 Name

First NameLast Name
Caregiver 2 Email
Caregiver 2 Cell Phone Number

Area CodePhone Number
Address*

Street Address

Street Address 2

CityState

Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*

Area CodePhone Number
Emergency Contact Relationship to Girl*
Troop Number*
Troop Leader Name*

First NameLast Name
Troop Leader Email*
example@example.com
Health Insurance Information
Name of Insurance Company*
Insurance Company Phone Number*

Area CodePhone Number
Policy Holder Name*

First NameLast Name
Member or ID Number*
Policy or Certificate Number*
Health History

Allergies (Please list specifics)

	Details
Animals
Food
Hay Fever
Insect Stings
Medicine/Drugs
Plants
Pollen
Other

Chronic or Recurring Illnesses (check all that apply)

Ear InfectionsHeart Defect/DiseaseSeizuresBleeding DisordersAsthmaHypertensionDiabetesMusculoskeletal DisodersOther

Other (Please list specifics)

	Details
Fainting
Constipation
Sickle Cell trait or disease
Motion Sickness
Wears Contacts
Wears Glasses
Homesickness
Nosebleeds
Hearing Impairment
Sleep Disturbances
Bed Wetting
Mental/Behavioral Health

My girl has permission to take or use the following (check all that apply):

Tylenol/acetaminophenAdvil/ibuprofenSudafed/decongestantBenadryl/antihistaminePepto BismolTums/antacidRobutussin/expectorantSwimmer's ear/alcohol-vinegar solution
Has your girl menstruated?

YesNo
If not, has she been told what to expect?

YesNo
Explain any specific needs or accommodations required:
Explain any known behavioral and/or emotional problems:
Explain any surgeries, hospitalizations, or chronic illnesses:
Explain activities that should be encouraged:
Explain any activities that are discouraged or limited:
Explain any dietary modifications:
Medical Provider Information
Licensed Physician Name*
Physician's Phone Number*

Area CodePhone Number
Immunization History

Immunization Dates*

	Year Primary Series Completed	Year of Last Booster
DTP (Diphtheria, Pertussis, Tetanus within last 10 years)
Td
Oral Polio
Measles
Mumps
Rubella
Hepatitus B
Tuberculin test given (most recent)

Authorization for Medical Care
This health history is complete and accurate to the best of my knowledge. The person herein described has permission to engage in all activities except as noted. I hereby give permission to the First-Aider or Adult-In-Charge to provide routine health care and witness prescribed medications. I consent for my child to receive such medical treatment and/or surgical procedures as are deemed necessary in the event of an emergency and to assume liability for any medical expenses involved. This authorization extends to my child’s participation in any activity sponsored by Girl Scouts of the USA, Girl Scouts, Hornets' Nest Council or individual units. Should a medical emergency arise during my child’s participation in a Girl Scout-sponsored activity, I understand that reasonable efforts will be made to contact me or my designated alternate at the phone numbers I have given. If it is believed my child’s life or health may be adversely affected by the delay that an attempt to contact me or my designated alternate would cause, I consent to the administration of medical treatment and/or surgical procedure deemed necessary by the medical doctor and/or medical facility and the immediate administration of life-sustaining measures deemed necessary under the circumstances.

If permission for emergency medical treatment is not given, please prepare a signed statement providing the reason, a release of liability, and alternate instructions and provide a copy to both your troop leader and Girl Scouts, Hornets' Nest Council.
Caregiver Signature
Caregiver Signature*

Clear
Should be Empty:

Health History and Consent to Administer Medical Treatment

Contact Information

Health Insurance Information

Health History

Medical Provider Information

Immunization History

Authorization for Medical Care