Girl Health History Form
Girl Scouts of Orange County
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  • If above contacts are not available in an emergency, notify this contact.
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  • Health History Information

    If you check any of the boxes below, please explain below.
  • This health history is complete and accurate. My daughter has permission to engage in all activities, except as noted by me.

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  • (girl's name) a minor, do hereby authorize consent to any x-ray
    examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provision of the Medicine Practice on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render or which the aforementioned physician in the exercise of his/her judgment may deem advisable.

    It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient but that any of the above treatments will not be withheld if the undersigned cannot be reached. I will not hold liable the Girl Scout Council of Orange County, its officers or leaders for medical aid rendered at a hospital or first aid rendered at the
    event and will reimburse the Girl Scout Council of Orange County for medical or other expenses incurred in the care of my daughter.

    This authorization is given pursuant to Section-6910 of the Civil Code of California.

    I will permit photographs of my daughter taken at this event to be used for publicity by authorization of the designated members of the Council.

    Medication must be accompanied by written instructions from the parent or physician and in their original containers.
  • ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY RELATING TO CORONA VIRUS/COVID-19
    I understand that: Novel coronavirus (‘‘COVID-19”) infections have been confirmed throughout the United States, including multiple cases in my area. COVID-19 is an extremely contagious virus that spreads easily, including through person-to-person contact.

    • As with any social activity, use of Girl Scouts of Orange County (GSOC) facilities or services, or participation in in-person troop, group, service unit or Council programs, may present the risk of contracting COVID-19. While GSOC takes safety and preventative precautions, GSOC can in no way warrant that COVID-19 infection will not occur through use of such facilities or services or participation in in-person Girl Scout activities and meetings.
    • I agree to comply and to ensure compliance by my children with the most recent guidance and recommendations issued by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and my local state agency or municipality for slowing the transmission of COVID-19. I agree that neither I nor my participating children shall visit or utilize the facilities, services, and/or programs of GSOC within 14 days after (i) returning from highly-impacted areas subject to a CDC Level 3 Travel Health Notice, (ii) exposure to any person returning from areas subject to a CDC Level 3 Travel Health Notice, (iii) exposure to any person who has a suspected or confirmed case of COVID-19, or (iv) exposure to any other risk identified by the most recent guidelines or recommendations or guidelines situation delineated by WHO, the CDC or my state public health agency or municipality. I further agree that neither I nor my participating children shall participate in, visit or utilize the facilities, services, and/or programs of Council if I, he, or she (i) experience(s) symptoms of COVID- 19, including, without limitation, fever, cough, loss of sense of taste or smell, or shortness of breath, or (ii) has a suspected or diagnosed/confirmed case of COVID-19. I agree to notify Council immediately if I believe that any of the foregoing access/use restrictions may apply. *
    • By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by use of GSOC facilities or services, or participation in in-person Girl Scout activities and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at GSOC facilities or services, or participation in in-person Girl Scout activities may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Girl Scouts of Orange County employees, volunteers, and Girl Scout-related activity participants and their families.

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  • This consent shall remain effective for one year from the date above.