Adult Health History

This form must be on file for all participants in the First Aide Station while you are at camp/teen trek.  This data is required by GSCNC and Maryland State Health Department.
Do NOT use [ENTER] Key in any TEXT FIELD BELOW.  This will give us 2 or more records, ALL CORRUPT! Let it wrap.

First Name: Middle Initial  
Last Name:
E-mail
Street Address
City
State       Zip Code
  Sex:      Female     Male
Date of Birth  (mm/dd/yyyy)     Age:    
 
ALLERGIES
  Insect Bites/Stings Plant, Ivy/Oak  Drugs/Medication  
  Hay Fever      Food  Plants Other Allergy  
 Please specify any accommodations that are needed:
 
           
Health Concerns:      
  Ear infections Asthma Diabetes  
Convulsions Skin conditions Epilepsy  
Heart Disease Fainting Nose Bleeds  
  Other      
 Please specify any accommodations needed:.
 
         
Disabilities:    
ADD/ADHD    Emotional Disability Learning Disability  
Physical Disability Visual Disability Deaf or hard of Hearing  
  Other      
 Please specify any accommodations needed:.
 
 
Operations or serious injuries?  - Describe, if checked:    
 
Are all immunizations up to date?  Yes     No - If not, please state reason:

Date of last Tetanus shot (DTP or DT):  

 (mm/dd/yyyy)
   
Medication Information: 
Any prescribed medication being taken?  Yes     No Inhaler Epi-pen

If yes, please list medication and dosage: 

 

 
 

General Information
Physician Name:
Physician Phone:   (999-999-9999)
   

Health Insurance Company:
Policy Number:
Company Street:
City:
State:     
Zip Code:
   
Emergency Contact Information: (must be able to come to camp to get you if necessary)

          POC #1 Name: 

Relationship:
Day Phone:   (999-999-9999)
Eve Phone:   (999-999-9999)
Cell Phone:   (999-999-9999)

          POC #2 Name: 

Relationship:
Day Phone:   (999-999-9999)
Eve Phone:   (999-999-9999)
Cell Phone:   (999-999-9999)
   
 
Additional Comments:

IMPORTANT – THIS SECTION MUST BE COMPLETED
This health history is correct so far as I know. I can 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 administer prescribed medications. I consent 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 participation in any activity sponsored by GSUSA, GSCNC or individual units. Should a medical emergency arise during my participation in a Girl Scout-sponsored activity, I understand that reasonable efforts will be made to contact my designated alternate at the phone numbers I have given. If it is believed my life or health may be adversely affected by the delay that an attempt to contact 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. This form will not be returned.

Signature (//name//)
 

Revised: 06/18/11 14:13