In case of emergency notify ______________________________
Address _____________________________Tel No: _____________ TO WHOM THIS MAY CONCERN: HEALTH HISTORY: (Check by giving appropriate date) Frequent colds ________Kidney Trouble _______Chickenpox_____________ This is to permit my daughter Abscessed Ears __________ Convulsions _________Mumps _____________ ____________________________________ Fainting ____________ Sleep Walking ________ Whooping cough __________ of _____________________________ to Frequent Sore Throat ______________ Heart trouble _____________________ participate in the Sinusitis _____________ Measles ____________ Bronchitis _______________ _____________________________________ Athlete’s Foot __________________ Stomach upsets ____________________ _____________________________________ Constipation__________________ Tuberculosis ________________________ ________________________ to be held at Operations or other serious injuries ___________________________________ _____________________________________ Allergic Reactions : Penicillin : ___________________ Other drugs: _________________ _____________ on ___________________. Details of the above or additional information______________________________________ We will not hold the Girl Scouts of the Philippines-Quezon Council responsible for any untoward incident Any specific activities to be encourage? ________________________________ that may happen beyond their control. RESTRICTED ____________________________________________________
General condition__________________________________________________ _____________________________
Parent’s Signature Physician: _________________________________________________ Noted: IMPORTANT: Please notify the Training/Camp Staff is this applicant is exposed to any _______________________ communicable disease during the three weeks prior to camp attendance. Troop Leader
GIRL SCOUTS OF THE PHILIPPINES
Southern Luzon Region Quezon Council
HEALTH EXAMINATION FORM PARENTS CONSENT FORM
In case of emergency notify ______________________________
Address _____________________________Tel No: _____________ TO WHOM THIS MAY CONCERN: HEALTH HISTORY: (Check by giving appropriate date) Frequent colds ________Kidney Trouble _______Chickenpox_____________ This is to permit my daughter Abscessed Ears __________ Convulsions _________Mumps _____________ ____________________________________ Fainting ____________ Sleep Walking ________ Whooping cough __________ of _____________________________ to Frequent Sore Throat ______________ Heart trouble _____________________ participate in the Sinusitis _____________ Measles ____________ Bronchitis _______________ _____________________________________ Athlete’s Foot __________________ Stomach upsets ____________________ _____________________________________ Constipation__________________ Tuberculosis ________________________ ________________________ to be held at Operations or other serious injuries ___________________________________ _____________________________________ Allergic Reactions : Penicillin : ___________________ Other drugs: _________________ _____________ on ___________________. Details of the above or additional information______________________________________ We will not hold the Girl Scouts of the Philippines-Quezon Council responsible for any untoward incident Any specific activities to be encourage? ________________________________ that may happen beyond their control. RESTRICTED ____________________________________________________
General condition__________________________________________________ _____________________________
Parent’s Signature Physician: _________________________________________________ Noted: IMPORTANT: Please notify the Training/Camp Staff is this applicant is exposed to any _______________________ communicable disease during the three weeks prior to camp attendance. Troop Leader