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.