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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 


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