GIRL HEALTH HISTORY
Date
Instructions: Complete form and secure parent/guardian signature and submit to troop/group
leader or event director.
Girl’s Name
Address
Street
City
State
Name of family physician
Zip
Phone
INSURANCE INFORMATION
Is the participant covered by family medical/hospital insurance?
If so, indicate carrier or plan name
Yes No
Group #
HEALTH HISTORY
List any physical or behavioral conditions that may be useful to the adult in charge or which may limit full
participation in Girl Scout activities:
Allergies (medication, food or other)
RESTRICTIONS – The following restrictions apply to this individual:
Does not eat red meat
Does not eat shellfish
Allergy to latex
Does not eat pork
Does not eat eggs Does not eat dairy products
Does not eat poultry Does not eat peanuts
Allergy to stinging insects
Other
MEDICATIONS—Leaders are not required to dispense medication.
Prescription and over-the-counter medicines must be sent in their original container with the physician prescribed
orders including instructions and given to the troop leader/first aider.
Permission to use and carry self-administered emergency medication:
I confirm that my child has the knowledge and skills to safely have readily available (carry or possess outside of the regular supervision of
the troop leader/first aider) and self-administer the indicated emergency medication as medically necessary at Girl Scout activities. They
need to notify the troop leader/first aider if they have to use th Z\