Minors Name:										Date of Birth:
Last				First				M.I.			M/D/Y			
Parents Name												
Home Address												
City				State		Zip			Home Phone				
Mother’s Employer							Work Phone				
Father’s Employer							Work Phone				
Insurance Carrier Name and Address									
Policy No.													
#1 Notify in Emergency (if unable to reach parents)							
City					State				Phone					
#2 Notify in Emergency (if unable to reach parents)							
City					State				Phone					
Family Physician							Phone					
Allergies													
Medical Problems												
														
Current Medication (name,dosage,frequency)								

Authorized Treatment of a Minor
I, the undersigned, parent or legal guardian of					,a minor do hereby consent to the nurse or physician selected by the Girl Scout Leader to perform routine tests and treatment for the health of my child.  In the event I cannot be reached in an emergency, I hereby give permission for the physician selected by the Girl Scout Leader to hospitalize, secure proper treatments for, and to order injection, anesthesia, or surgery for my child as named above.

Date:			Signature of Parent/Guardian							

Permission to Dispense Medication
I, the undersigned give permission to the Girl Scout Leader in charge to administer the following medications to my child as named above.

Yes		No								Dosage		
					Acetaminophen(Tylenol)					
					Benadryl							
					Benadryl Cream			As needed
					Low DEET insect repellent		As needed

Date:			Signature of Parent/Guardian