ࡱ> q` WbjbjqPqP |:::::8r64,xvTDT$+++++++$W.h0d ,x ^x x ,,(((x dR+(x +(()h`"n*j 0I: |N*R+,0,^*#1X!#1 n*#1n*x x (x x x x x , ,n$x x x ,x x x x  :: Instructions This card, signed by the parent or guardian, is needed prior to a girl participating in Girl Scout activities lasting two nights or less. This includes troop meetings, day trips, weekend camping trips, and one or two night troop trips. Adults are encouraged to provide their own Health History Card in case of an emergency. Parents may wish to make a copy in case daughter participates in Girl Scout program events without her troop. Name  FORMTEXT       Phone ( FORMTEXT       )  FORMTEXT       Date of Birth FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Name of Parent or Guardian  FORMTEXT       Work #  FORMTEXT       Other  FORMTEXT       Family Physician Name  FORMTEXT       Telephone  FORMTEXT       Family Medical/Hospital Insurance Carrier  FORMTEXT       Policy #  FORMTEXT       Group #  FORMTEXT       Preferred Hospital Name (include city)  FORMTEXT       Telephone  FORMTEXT       Date of Last Medical Exam  FORMTEXT       Are Immunizations Up To Date  FORMTEXT       Date of Last Tetanus Immunization  FORMTEXT       Current Medications (Identify medication and explain condition being treated)  FORMTEXT       Please check all that apply: Since her last health exam has your daughter had:  FORMCHECKBOX  Serious injury requiring medical attention?  FORMCHECKBOX  Treatment in a hospital or emergency room?  FORMCHECKBOX  Exposure to a contagious disease?  FORMCHECKBOX  Illness lasting more than 5 days?  FORMCHECKBOX  Surgical operation or fracture?  FORMCHECKBOX  Physical activity restriction?Allergies:  FORMCHECKBOX  Animals  FORMCHECKBOX  Bee Stings  FORMCHECKBOX  Food  FORMCHECKBOX  Hay Fever  FORMCHECKBOX  Insect Stings  FORMCHECKBOX  Medicines/Drugs  FORMTEXT        FORMCHECKBOX  Plants  FORMCHECKBOX  Pollen  FORMCHECKBOX  Other (Specify)  FORMTEXT       Chronic or Recurring Illness:  FORMCHECKBOX  Asthma  FORMCHECKBOX  Bleeding/Clotting Disorders  FORMCHECKBOX  Diabetes  FORMCHECKBOX  Ear Infection  FORMCHECKBOX  Heart Defect/Disease  FORMCHECKBOX  Hypertension  FORMCHECKBOX  Musculoskeletal Disorders  FORMCHECKBOX  Seizures  FORMCHECKBOX  Other (Specify)  FORMTEXT       Other Health Conditions:  FORMCHECKBOX  Bed Wetting  FORMCHECKBOX  Constipation  FORMCHECKBOX  Emotional Disturbances  FORMCHECKBOX  Fainting  FORMCHECKBOX  Hearing Impairment  FORMCHECKBOX  Motion Sickness  FORMCHECKBOX  Nosebleeds  FORMCHECKBOX  Special Dietary Regimen  FORMCHECKBOX  Wears Glasses or Contact Lens  FORMCHECKBOX  Other (Specify)  FORMTEXT       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.  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I know of no reason(s), other than the information on this form, why my daughter should not participate in prescribed activities except as noted. I understand that medication needing to be administered to my daughter during a Girl Scout activity must be given to the adult in charge along with written instructions and permission to administer the scheduled dosage(s). Medical Release: In the event  FORMTEXT       becomes ill or sustains an injury while in the care of or under the supervision of Girl Scouts Heart of the South or any of its officers or leaders and it becomes necessary to seek professional medical treatment, I give my permission to the certified first aider to provide First Aid and/or CPR and to take the appropriate measures including contacting the emergency medical services system and arranging transportation to  FORMTEXT       or the nearest emergency medical facility to receive treatment by a licensed physician. I understand that every effort will be made to contact me or the person designated by me as my emergency contact.  FORMCHECKBOX  Yes  FORMCHECKBOX  No Initial  FORMTEXT       Photo/Voice Release : The council has my permission to make and use photographs, videos, and/or audio-tapes of my daughter, or any words written or spoken by her for the promotion of Girl Scouting.  FORMCHECKBOX  Yes  FORMCHECKBOX  No Initial  FORMTEXT       Signature of parent or guardian  FORMTEXT       Date  FORMTEXT       Typing your name here qualifies as a valid signature     Girl Scouts Heart of the South  Girl and Adult Health History Card (and Medical & Photo/Voice Release)  Girl Scout Leader/Advisor Keep cards with first-aid kit. 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