Annual Permission Slip & Health History
form #120 • 07/16 • page 1 of 1
Complete this form at registration time. This form will be retained by the troop/group
leader.
October 1, 20______ to September 30, 20______
Special Accommodations
My child requires the following special accommodations: _____________________________________________________________
(write “none” if there are none)
Health History
This health history is complete and accurate. My child has permission to engage in all prescribed activities, except as noted by
me. In case of illness or injury, I/we give permission for her to receive first aid, and to receive emergency treatment from a licensed
physician, emergency medical services, or other health care professional. It is understood that all reasonable efforts will be made to
contact the parent or guardian.
If permission for emergency medical treatment is not given, please prepare a signed statement
providing the reason, a release of liability, and alternate instructions and attach to this form.
Check all that apply:
Name Troop Date of Birth
Street Address City State ZIP Code
Permission for Trips Yes No* Initialed ___________
My child has permission to travel to, attend and participate in troop and council-sponsored activities that are 1.) Three (3) nights or
less, and 2.) Not considered high-risk activities as outlined by Girl Scouts. Leaders will be notifying parents/guardians of activities
planned. (*By checking “No”, I am requesting to sign individual permission slips for each activity.)
Permission to Use Photographs
Yes No Initialed __________
I hereby consent that the videotapes, photographs, motion pictures, electronic images and/or audio recordings of my child may be used by
Girl Scouts for public relations and publicity purposes. (I understand that her name and residence will not be used for publicity purposes.)
Permission for Emergency Medical Treatment
Yes No Initialed __________
In the event of an emergency, every effort will be made to contact a parent/guardian or emergency contact. If no contact can be
made, I hereby give authorization to Girl Scouts of Oregon and Southwest Washington to seek treatment for my child and/or depen-
dent minor by a licensed physician or dentist. I know of no reason(s) why my child may not participate in prescribed activities except
as noted on the health history form.
Emergency Contact
Name Telephone(s) Relationship to Child
Name Telephone(s) Relationship to Child
Parent Agreement I have read and understand this annual permission form. I may change or revoke any aspect of this agreement at any time by submitting
my request, in writing, to the troop/group leader.
Printed Name of Parent/Guardian Signature of Parent/Guardian Date
Street Address (if different from girl’s) City/State/ZIP E-mail Address
Home Telephone Work Telephone Mobile Telephone Other Telephone
Allergies:
Animals ______________________________________________________
Food ________________________________________________________
Peanut ______________________________________________________
Hay fever ____________________________________________________
Insect stings __________________________________________________
Medicine/drugs _______________________________________________
Plants _______________________________________________________
Pollen _______________________________________________________
Other (specify) ________________________________________________
Chronic or Recurring Illness:
Heart defect/disease ___________________________________________
Seizures _____________________________________________________
Bleeding/clotting _______________________________________________
Asthma ______________________________________________________
Diabetes _____________________________________________________
Other (specify) ________________________________________________
Had any restrictions concerning:
physical activities? __________________________________________________
Please describe any conditions: ________________________________________
