Annual Permission Form & Health History

Annual Parent Permission Form
October 1, to September 30,
Troop/Group Leader agrees to:
 notify all parents/guardians of any trip/activity outside of the normal meeting place or time.
 request updated emergency contact information for each trip/activity.

Troop/Group Leader Name Signature Date

Girl Scout Name *

Troop

Birthdate *

Grade in Sept 2018 *

School

Parent Information

Parent/Guardian Name *

Home Phone

Cell Phone

Work Phone

Email Address *

OK to text?

Yes

No

Address *

Address

City

State/Province

Zip/Postal

Country

Emergency Contact

Name *

Home Phone

Cell Phone

Relationship *

Please Indicate:

Permission for Trips*: My daughter/dependent has permission to travel to, attend and participate in the following troop/group and Council-sponsored activities:

Activities within 1 hour driving time of the meeting place and not exceeding 6 hours in duration. *

Yes

No

All activities, except those considered high-risk* or involving an overnight stay. *

Yes

No

*High-risk activities and overnight/extended trips require an individual Parent Permission form.

Permission to Use Photographs: *

Yes

No

I hereby consent that my daughter’s/dependent’s name, image, and likeness, as shown in the videotapes, photographs, motion picture film and/or electronic images and/or audio recordings made of her voice may be used by Girl Scouts of the U.S.A., its assigns or successors, in whatever way they desire, including television and Web sites; furthermore, I hereby consent that such photographs, films, recordings, electronic images, and the plates, tapes and/or software from which they are made shall be their sole property, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, recordings, electronic images, plates, tapes and software as they may desire free and clear of any claim whatsoever on my part.

Permission to Register Daughter/Dependent Online: *

Yes

No

I hereby consent for the leadership of this troop to register my daughter/dependent online for the current membership year.

Permission to give Medication: *

Yes, as follows:Yes, as follows:

No

I hereby consent for the leadership of this troop to dispense over-the-counter medication and/or prescribed medication as listed below:

Special Accomodations:

Parent Agreement: I have read and understand this Annual Parent Permission Form. I will notify the troop/group leader of any changes in emergency contact information. I may change or revoke any aspect of this agreement at any time by submitting my request, in writing, to the troop/group leader.

Signature *

Draw It
Type It
Clear

Date

Girl Health History

Name of Family Physician *

Physician's Phone Number *

Medical Insurance Carrier *

Policy or Group Number *

Date of Last Medical Examination

Were any complicating medical problems noted in last health examination?

Part II: Allergies (Check those that apply and specify nature of allergic reaction.)

Please explain any items that are checked. Indicate any information useful to the adult in charge in relation to any of these health conditions. Also, indicate any activities to be encouraged or restricted.

Immunizations

Please indicate, to the best of your ability when your daughter had her original vaccinations and most recent booster.

DTP Primary Series

DTP Booster

Td Primary Series

Td Booster

Measles Primary Series

Measles Booster

Mumps Primary Series

Mumps Booster

Rubella Primary Series

Rubella Booster

Polio Primary Series

Polio Booster

Hib Primary Series

Hib Booster

Most recent Tuberculin Test result

Current Medications

(need to be in original container with dosage)

Dietary Restrictions *

Write "none" if there are none.

Permission for Emergency Medical Treatment
In the event of an emergency, every effort will be made to contact a parent/guardian or emergency contact. If no contact can be made, I hereby give authorization to Girl Scouts of Colorado to seek treatment for my child and/or dependent minor by a licensed physician. I know of no reason(s) why my daughter/dependent may not participate in prescribed activities except as noted on the Health History form. 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 submit to troop leader.

I know of no reason(s), other than the information indicated on this form, why my daughter should not participate in prescribed activities except as noted.

Signature (Health History)

Draw It
Type It
Clear

Date