Girl Scouts of Western Ohio
HEALTH INFORMATION AND RELEASE FORM
To be completed and reviewed annually by parent/guardian or adult. This form should be kept with the troop/group records and accompany the troop/group leader on all troop/group activities. It is designed to provide the troop/group leader with the information needed to access medical care for your daughter. It should be reviewed and updated (as needed) when information changes.
Name
Date of Birth
Month Day Year
Date
Phone Number
Address:
City, State, Zip:
Troop #:
PART I: PARENT INFORMATION AND RELEASE
She is under the custodial care of:
Both Parents Mother/Guardian Only Father/Guardian Only
Mother/Guardian Name
Address (if different than girl):
Employer:
Occupation:
Phone (day):
Phone (evening):
Cell Phone:
Email:
example@example.com
Father/Guardian Name
Address (if different than girl):
Employer:
Occupation:
Phone (day):
Phone (evening):
Cell Phone:
Email:
example@example.com
PART II: EMERGENCY CONTACT AND RELEASE INFORMATION
In the event that I cannot be reached in an emergency, the following are authorized to act in my behalf:
Name:
Relationship to Participant:
Address
Address
Street Address Line 2
City State
Zip
Home Phone:
Work Phone:
Cell Phone:
Name:
Relationship to Participant:
Address
Address
Street Address Line 2
City State
Zip
Home Phone:
Work Phone:
Cell Phone:
ADDITIONAL RELEASE INFORMATION:
In addition to the above parent(s)/guardian(s) and emergency contacts, this participant may also be released to the following persons:
Name:
Relationship to Participant:
Name:
Relationship to Participant:
PART III: HEALTH CARE INFORMATION:
Physician’s Name:
Phone:
Address
Physician’s Address
Street Address Line 2
City State
Zip
Dentist’s Name:
Phone:
Address
Dentist’s Address
Street Address Line 2
City State
Zip

	Year Primary Series Completed	Year of Last Booster
DTP (Diphtheria; Tetanus; Whooping Cough)
Hepatitis B
MMR (Measles/Mumps/Rubella)
Oral Polio
TD (Tetanus/Diphtheria)
Tuberculin Test (most recent) Result
Others:

	Name	Being Taken for (Condition)	Dosage and Frequency
Medication 1
Medication 2
Medication 3

Girl Scouts of Western Ohio

HEALTH INFORMATION AND RELEASE FORM

PART I: PARENT INFORMATION AND RELEASE

PART II: EMERGENCY CONTACT AND RELEASE INFORMATION

ADDITIONAL RELEASE INFORMATION:

PART III: HEALTH CARE INFORMATION:

PART VI: IMMUNIZATION HISTORY

Immunization