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APPLICATION FORM HEALTH EXAMINATION FORM PARENTS CONSENT FORM CAMPER’S COPY

SCHOOL_________________________________ Name ____________________________________ To Whom It May Concern: ( Please detach )

PERSONAL DATA: Health History: (Check giving approximate dates) THINGS TO BRING:

1. Name _____________________________ Frequent Colds: ___________________________ This is to permit my daughter -Parent’s Consent
2. Date of Birth ________________________ Kidney Trouble: ____________________________ to participate in the _______________ -Medical Certification
3. Home Address ______________________ Chickenpox: ____________________________ _______________________________ -Official Uniforms
__________________________________ Abscessed Ears: ___________________________ _______________________________ - GSP T-shirt, maong pants,
4. Mobile Number:______________________ Convulsions : ______________________________ held at _________________________ jogging pnats, extra shirt
5. Parent/ Guardian : ___________________ Mumps: __________________________________ _______________________________ and sleeping gears
___________________________________ Fainting: __________________________________ on ____________________________. - Black close shoes, rubber
6. Person to notify in case of Emergency: Sleep Walking: ____________________________ shoes and rubber slippers
Name: ______________________________ Whooping Coughs: _________________________ - personal effects and toiletries
Address: ____________________________ Frequent Sore Throat: _______________________ We will not hold the Girl Scouts - flashlight, sit upon
____________________________________ Measles: __________________________________ of the Philippines responsible for any - bedroll, beddings
7. Religious Affiliation: ___________________ Heart Trouble: _____________________________ untoward incident that may happen beyond - prescribed medicine
8. Food Prohibition ______________________ Bronchitis: ________________________________ their control. - dome tents

SCOUTING DATA: Stomach Upsets: ___________________________ - garbage bags


- pails

1. Program Level:________ Troop No. _______ Rheumatic Fever: ___________________________


2. Date of Last Registration:________________ Constipation: _______________________________
3. Camping Experience: Tuberculosis: _______________________________
District/ School ________________________ Operations or serious injuries: __________________
Provincial Encampment _________________ Allergic Reactions: ___________________________ ______________________________
Regional Encampment:__________________ Penicillin:____________________________ Parent/ Guardian

Other Drugs: ________________________ (Signature over printed name)


________________________________________ IMPORTANT: Please notify the Council if this applicant is
Signature of Applicant exposed to any communicable diseases 3 weeks
Prior to Trip attendance.

_____________________________________ _____________________________________
Name of Field Adviser/School Coordinator Licensed Physician