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

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