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Nmgirlscouts.org

Health Care Information
Camper/Staff/Volunteer Name:
Custodial Care and Contact Information (required for participants under the age of 18)
My participant is under the custodial care of (check one):
 Both Parents Mother Only Father Only Other (list name and relationship)
Parent/Guardian Name:
Emergency Contact (required for ALL persons. Must be different than above in case parent/guarding cannot be reached)
Name
Insurance Information
Is the participant covered by family medical/hospital insurance?  Yes  No Health History (required for ALL persons. This information will provide healthcare personnel with the background to provide
appropriate care. Any changes should be shared with Troop/event/camp personnel.
Allergies
List all known (medications, food, insect stings, hayfever,
etc, and describe reaction and management of the reaction.
Medications
List all medications (including over-the-counter or non- prescription) the person takes routinely. Bring enough medication in the ORIGINAL packaging/bottle with its prescription or over-the-counter label to last the entire event/camp session. By completing this information, you are giving permission for event/camp staff or the appointed first aider to administer the medications listed. taking
Summer Camp/Programs only: This participant takes the following medications during the
school year which she does not/may not take during the summer:
Mental / Emotional Health
This participant has had a significant life event that continues to affect their life/health? The following mental, emotional, and psychological health information will help our professional event/camp staff prepare and provide the best care for all participants. This participant has an emotional health concern that will impact their participation?  Yes  No If yes, please explain: Immunizations Date
Doctor Information
Special Dietary Restrictions
Does not eat: (circle) red meat pork poultry eggs dairy seafood gluten The following dietary restrictions apply to this individual:
Special Activity Restrictions
Explain any restrictions to activity (i.e. what cannot be done, what adaptations or limitations are necessary) Camper Name: _________________________________________________________________________________________________

General Health Information
Has/does the participant.
Had recent injury, illness/infectious disease? Brought an orthodontic appliance to camp? Have a chronic or recurring illness/condition? Have any skin problems (itching, rash, etc.)? Had mononucleosis in the past 12 months? Had problems with diarrhea/constipation? Wear glasses, contacts or protective eyewear? Ever passed out during or after exercise? Ever been dizzy during or after exercise? Ever had chest pain during or after exercise? Ever been diagnosed with a heart murmur? Ever had joint problems (knees, ankles, etc.)? Had lice, ringworm or scabies in the past two months? Ever had emotional difficulties for which professional If you answered yes to any question, please explain, noting question number being referenced.

Permission for Basic Medical Treatment
By checking off the following items, I (parent/guardian) hereby give permission for the Troop leader, event/camp staff, or appointed first aider to
administer the marked over-the-counter medications or generic equivalents if the onsite health care personnel deems it to be necessary. Dosage will be
administered according to directions on the product.
 Acetaminophen/Tylenol – Adult or Children (headache,
 Ibuprofen – Adult or Children (headache, menstrual cramps, muscle  Tecnu/Rhullgel/Ivy Dry/Calamine lotion (poison ivy, bug bites)  Ludens Throat Drops/Cipacol lozenges/Chloraseptic (sore throat)  Children’s Pepto-Bismol/Tums/Rolaids (upset stomach/diarrhea)  Benadryl – Adult or Children – liquid or lotion (insect bites, allergy  Triple Antibiotic Cream/Neosporin (skin abrasions/minor cuts &  Talcum Powder/Baby Powder (skin irritations, heat rash)  Sudafed liquid or tablets (stuffy nose)  Claritin, Claritin D (allefgy symptoms)  Hydrocortisone cream (insect bites, sunburn)  Foille/Solarcaine/Aloe Vera Gel (sunburn)  Oatmal Bath – Aveeno or similar (poison ivy)  Epsom Salt (muscle strains, skin irritations)  Desitin (skin irritations, heat rash)  Hydrogen Peroxide (minor cuts, scrapes, burns)  Campho-Phenique (cold sores, insect bites, sunburn)
Signatures – Important – Must be Completed for Attendance
This health history is correct and complete as far as I know. The person herein described has permission to engage in all prescribed Girl Scout activities
except as noted. _____ (Initials of Parents/Guardian/Adult Participant/Volunteer/Staff)
I hereby give permission to the acting first aider (first aid trained troop volunteer, event/camp staff) to provide, seek, and consent to routine health care, administration of
prescribed medications, and emergency treatment for me/my child as may be necessary, including, but not limited to, x-rays, routine tests and treatment, and/or
hospitalization. I also give permission for the Troop/event/camp staff to arrange related transportation. I agree to the release of any records necessary for treatment, referral,
billing, or insurance purposes. It is my intention that the troop leader or event/camp staff be treated as acting in loco parentis if the person herein named is a minor. Further,
it is my intention that the appropriate representatives of the troop/event/camp be treated as “personal representatives” for the purpose of disclosing protected health
information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR
164.510(b) to the disclosure to troop/event/camp representatives of the protected health information of the person herein described, as necessary: (i) to provide relevant
information to the troop/event/camp representatives related to the person’s ability to participate in program activities; (ii) in the case of minors, to provide relevant
information to the troop/event/camp representatives to keep me informed of my child’s health status.
In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the troop/event/camp to secure and administer
treatment, including hospitalization, for the person named above. This completed for may be photocopied for trips out of camp.
Signature of Parent/Guardian/Adult Participant/Volunteer/Staff: _______________________________________________________________________
Printed Name: _______________________________________________________________________________________ Date: __________________
* If for religious reasons you cannot sign this, contact Girl Scouts of New Mexico Trails Council for a legal waiver which must be signed for attendance.
I agree to abide by the restrictions placed on my event/camp activities.
Signature of Minor/Adult Participant/Volunteer/Staff: ________________________________________________________ Date: __________________

Source: http://nmgirlscouts.org/uploads/files/2013%20Camp%20Book%20-%20Health%20History.pdf

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