Financial Assistance Forms are available for download at www.girlscoutsgcnwi.org or by contacting any Gathering Place.
Girl/Individual Program
Registration Form
FOR OFFICE USE RECEIVED $____________
Register online at girlscoutsgcnwi.org or mail form to: Program Registrar, 2400 Ogden Ave., Suite 400, Lisle, IL 60532-3933
DATE _________________
SUBMIT ONE FORM AND PAYMENT PER PROGRAM Health history form must accompany girl to event/workshop. Girl Name: (Last)
(First)
Troop # (if applicable)
Address:
City/Zip
Phone: Level:
E-mail: Daisy
Brownie
Junior
I am currently a registered Girl Scout
(Confirmations will be e-mailed, so please print clearly)
Cadette
Senior
Ambassador
Grade:
I am registering now as a Girl Scout (*add $12)
Special needs/medical conditions: I am applying for financial assistance (attach Financial Assistance Application form)
Program Code
Program Date
Program Name
Program Fee
* New Member Fee
Total Due
Program 1 Program 2
Parent/Guardian Printed First and Last Name: I am available to lend a hand at this event. I have read and agree with the program information and refund procedure in this brochure and give my daughter/ward permission to attend. Any photographs or films taken in which my daughter appears may be used for promotion or as deemed appropriate by the Girl Scout council free of any claims on my part.
Yes
No
Parent/Guardian Signature: Payment (due now)
Date: Credit card
Debit Card
My check (payable to Girl Scouts). If registering for more than 1 program, please use separate checks.
Name (as it appears on card): Billing Address:
City/State/Zip:
Phone Number: (day) MasterCard Cardholder Signature:
(cell) Visa
Discover
Debit Card
Card #:
Exp. Date: Month/Year Date:
Page 73 Page 63
Confidential
Health History
This form must be completed and signed by parents/guardians of girls Girl Scouts of Greater Chicago and or by adult members themselves. All Health History forms will be held Northwest Indiana, Program Registrar in limited access by the trustee (leader/facilitator/staff) of the specific This form must be completed and signed by parents/guardians of girls or by adult members health 2400themselves. Ogden Ave.,All Suite 400 history Girl Scout program. The absolute minimal necessary information may formsinwill be to held in limited access by the trustee (leader/facilitator/staff) of the specific Lisle, Girl Scout program. The absolute be shared with program staff/volunteers order provide adequate IL 60532-3933 minimal necessary information adequate health care. health care. The Health History form will be retained by the Girl Scoutmay be shared with program staff/volunteers in order to provide T 630.544.5900; F 630.544.5999 The health history form will be reatined by the Girl Scout program trustee until it is destroyed. program trustee until it is destroyed. www.girlscoutsgcnwi.org
CONFIdeNTIAL
Health History
SeCTION A: memBeR INFORmATION Name
date of Birth
Age
Troop #
Address Parent/Guardian
Phone (
Home Address
)
City
Zip Code
Business Address
Phone (
)
If Parent/Guardian is unavailable, contact:
Relationship
Address
Phone (
)
Name of family physician
Phone (
)
SeCTION B: HeALTH HISTORy/ReCuRRING CONdITIONS
Check each applicable item, giving appropriate dates and comments ALLeRGIeS / deSCRIPTION Foods Insects Plants drugs Animals Hay fever Asthma Latex Other
AddITIONAL INFORmATION Operation/date Serious injury/date Sleepwalking Bedwetting Fainting Constipation Night disturbances Other
dATe OF LAST HeALTH exAmINATION: / were any complicating medical problems noted? Is participant now under the care of a physician/psychologist? List restrictions to swimming, diving, running, etc.
/
describe any medical/dietary regimen to be continued:
SINCe LAST HeALTH exAm, HAS THe PARTICIPANT HAd: A serious illness requiring medical attention? An illness lasting more than 5 days? A surgical operation or fracture? Treatment in a hospital or emergency room? Any restrictions concerning physical activities? exposure to a contagious disease? within the past month?
ReCuRRING CONdITIONS ear Infections Heart disease kidney Ailment Convulsions Bronchitis Frequent Colds Frequent Sore Throat Stomach upset diabetes Hyperactivity epilepsy Hearing Impairment vision Impairment Orthopedic Impairment Learning disability Other
dISeASeS / dATeS Chicken Pox measles German measles mumps Scarlet Fever Rheumatic Fever Poliomyelitis whooping Cough Other ImmuNIZATIONS / dATeS dPT Oral Polio measles Td (Adult Tetanus) mumps Rubella Tuberculin Test Tetanus Hib Hepatitis B Other
THIS FORm muST Be SIGNed
what?
duPLICATe THIS FORm AS Needed
SeCTION C: PAReNT/GuARdIAN muST COmPLeTe THe INFORmATION BeLOw I have read the above procedures for handling my/my daughter's health history information and I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. In case of emergency, I give permission for the First Aider(s) to administer medication, and/or First Aid ANd give permission to an attending physician to hospitalize or secure proper treatment/surgery for me/my child. I give permission to transport me/my child to the nearest emergency facility for treatment. I know of no reason(s), other than the information indicated on this form, why I/my child should not participate in prescribed activities except as noted.
Signature of parent/guardian
date
Page74 64 Forms Page
FORMS
Financial Assistance Forms are available for download at www.girlscoutsgcnwi.org or by contacting any Gathering Place.
Troop/Group Program
Registration Form Register online at girlscoutsgcnwi.org or mail form to: Program Registrar, 2400 Ogden Ave., Suite 400, Lisle, IL 60532-3933
FOR OFFICE USE RECEIVED $__________ DATE _______________
SUBMIT ONE FORM AND PAYMENT PER PROGRAM Health history form must accompany girl to event/workshop. Troop #:
Service Unit:
Leader/Volunteer:
Address:
City/Zip
Phone: #
E-mail: of girl participants
#
Program Code
(Confirmations will be e-mailed, so please print clearly)
of adult participants (if allowed) Program Date
Program Name
Program Fee
* New Member Fee
Total Due
Program 1 Program 2
I understand that participating troops must provide girl/adult ratio unless otherwise noted. I have read and agree with the program information and refund procedure in this brochure . I am available to lend a hand at this event. Payment (due now)
Credit card
Name: Debit Card
My check (payable to Girl Scouts).
Name (as it appears on card): Billing Address:
City/State/Zip:
Phone Number: (day) MasterCard
(cell) Visa
Discover
Debit Card
Card #:
Cardholder Signature:
Exp. Date: Month/Year Date:
List each girl attending: (attach additional sheet if needed) Girl (First and Last Name)
Level and Grade
Special Needs
Photo Permission on File
65 Page 75
Confidential
Health History CONFIdeNTIAL
This form must be completed and signed by parents/guardians of girls Girl Scouts of Greater Chicago and or by adult members themselves. All Health History forms will be held Northwest Indiana, Program Registrar in limited access by the trustee (leader/facilitator/staff) of the specific This form must be completed and signed by parents/guardians of girls or by adult members health 2400themselves. Ogden Ave.,All Suite 400 history Girl Scout program. The absolute minimal necessary information may forms will be held in limited access by the trustee (leader/facilitator/staff) of the specific Girl Scout program. The absolute be shared with program staff/volunteers in order to provide adequate Lisle, IL 60532-3933 minimal necessary information adequate health care. health care. The Health History form will be retained by the Girl Scoutmay be shared with program staff/volunteers in order to provide T 630.544.5900; F 630.544.5999 The health history form will be reatined by the Girl Scout program trustee until it is destroyed. program trustee until it is destroyed. www.girlscoutsgcnwi.org
Health History
SeCTION A: memBeR INFORmATION
Name
date of Birth
Age
Troop #
Address Parent/Guardian
Phone (
Home Address
)
City
Zip Code
Business Address
Phone (
)
If Parent/Guardian is unavailable, contact:
Relationship
Address
Phone (
)
Name of family physician
Phone (
)
SeCTION B: HeALTH HISTORy/ReCuRRING CONdITIONS
Check each applicable item, giving appropriate dates and comments ALLeRGIeS / deSCRIPTION Foods Insects Plants drugs Animals Hay fever Asthma Latex Other
AddITIONAL INFORmATION Operation/date Serious injury/date Sleepwalking Bedwetting Fainting Constipation Night disturbances Other
dATe OF LAST HeALTH exAmINATION: / were any complicating medical problems noted? Is participant now under the care of a physician/psychologist? List restrictions to swimming, diving, running, etc.
/
describe any medical/dietary regimen to be continued:
SINCe LAST HeALTH exAm, HAS THe PARTICIPANT HAd: A serious illness requiring medical attention? An illness lasting more than 5 days? A surgical operation or fracture? Treatment in a hospital or emergency room? Any restrictions concerning physical activities? exposure to a contagious disease? within the past month?
ReCuRRING CONdITIONS ear Infections Heart disease kidney Ailment Convulsions Bronchitis Frequent Colds Frequent Sore Throat Stomach upset diabetes Hyperactivity epilepsy Hearing Impairment vision Impairment Orthopedic Impairment Learning disability Other
dISeASeS / dATeS Chicken Pox measles German measles mumps Scarlet Fever Rheumatic Fever Poliomyelitis whooping Cough Other ImmuNIZATIONS / dATeS dPT Oral Polio measles Td (Adult Tetanus) mumps Rubella Tuberculin Test Tetanus Hib Hepatitis B Other
THIS FORm muST Be SIGNed
what?
duPLICATe THIS FORm AS Needed
SeCTION C: PAReNT/GuARdIAN muST COmPLeTe THe INFORmATION BeLOw
I have read the above procedures for handling my/my daughter's health history information and I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. In case of emergency, I give permission for the First Aider(s) to administer medication, and/or First Aid ANd give permission to an attending physician to hospitalize or secure proper treatment/surgery for me/my child. I give permission to transport me/my child to the nearest emergency facility for treatment. I know of no reason(s), other than the information indicated on this form, why I/my child should not participate in prescribed activities except as noted.
Signature of parent/guardian
date
Page 64 Page 76 Forms
FORMS