Microsoft word - new health form - ciss.doc

Girl Scouts of Shanghai
Health Information Form
Thank you for filling out this form. The more complete information you provide, the better we are able to work with your child to ensure she receives correct care when needed. Name of Child: (Last, First, Middle Initial)
Date of Birth: (MM/DD/YYYY)
Address:
District:
Postal code:
Parent or Guardian:
Mobile Phone:
Parent or Guardian:
Mobile Phone:

Additional Emergency Contact Information (if parent cannot be reached):
Emergency Contact:
Relationship:
Mobile Phone:

Health Insurance Information (Family insurance is primary insurance in case of accident or illness, Girl Scout
Policy Holder's Name:
Policy Number:

Insurance Company Name:
Group Number:

Insurance Company Address:
Insurance Company Phone:
Preferred Clinic in Shanghai:
Doctor’s Name:
Clinic Phone #:

Check all that apply and explain checked answers in detail:
☐ Diabetes ☐ Heart Problems ☐ Asthma ☐ Physical Restrictions ☐ Fainting ☐ Seizures ☐ Dietary restrictions ☐ Frequent nosebleeds ☐ Bleeding disorder such as hemophilia
Allergies: Please list all allergies, the type of reaction and its severity, treatment and date of last reaction. Include
allergies to medications, food, bees, animals, plants, etc. Allergies
Reaction/ Severity
Treatment
Date of Last Reaction
Girl’s Name:

If no allergies, skip to next section (Medical Conditions).
If yes allergies, please answer these 3 questions: 1. Does your daughter suffer from Anaphylaxis*? Yes *Anaphylaxis is a severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble
Medical Conditions (including any precautions or restrictions on activities)
Name of Condition

Prescription Medications: If your daughter is taking any prescription medications at the time of a hiking or camping
trip with Girl Scouts, it is your responsibility to inform the trip leaders. In that event, please inform a leader of dosage schedule, instructions for use, and whether girl can take the medication on her own or must be supervised.
Over-the-Counter (Non-Prescription) Medications: Please check which of these non-prescription medications the
leaders may give your daughter in case of health problem while on a trip. (They will try to contact you first.) Special notes regarding non-prescription
medications:

Sunscreen and Insect Repellent:
Please check below if you give permission for the leaders to apply the following to your daughter. If you do not give permission, please note below and send an alternative (e.g. sun hat, citronella patch). ☐ Sunscreen ☐ Insect repellent ☐ I do not give permission to apply these. I will provide the following alternatives:
Any other information not covered in this form that is important for your Girl Scout leaders to know:

This Health History Form is complete and accurate. My daughter has permission to engage in all activities,
except as noted by me.
Signature of Parent/Guardian:

Source: http://www.concordiashanghai.org/download/2013-14%20Girl%20Scout%20Health%20Form.pdf