Email
Phone Number
Name Nickname
Address Address line 2 City State Zip
Let us know which camp you volunteering for Big Soda LakeRueter-Hess
Adult women's t-shirt size: x-smallsmallmediumlargex-largexx-large
Emergency Contact Name Phone number Address Address line 2 City State Zip
Date of last health exam
Were there any complicating medical problems noted? YesNo If yes, please explain.
Health History: Please check any conditions you have had Ear infectionsDiabetesHeart defect/diseaseBleeding/clotting disorderHypertensionHypotensionSeizuresMusculoskeletal disorderSeizuresMusculoskeletal disorderAsthmaPlant/pollen allergiesInsect sting allergyDrug allergies (specify)Other allergies (specify)German measlesMumpsChicken pox Please explain health conditions checked above
Other health conditions: ConstipationMenstrual crampsMotion sicknessSleep disturbancesSpecial dietary regimenEmotional disturbancesFaintingNosebleedsHearing impairmentWear GlassesSickle cell trait or diseaseNoneOther Please explain other health conditions checked above. Indicate any information useful to the adult in charge in relation to any of these health conditions. Also, indicate any activities to be encouraged or restricted.
Are there other health concerns the Health Supervisor/Camp Directors should be aware of? YesNo If Yes, please explain health concerns Health Supervisor/Camp Directors should be aware of.
Since your last exam, have you had A serious injury requiring medical attention?Treatment in a hospital or emergency room?An illness lasting more than five (5) days?A surgical operation or fracture?Any restrictions concerning physical activities?Other Give dates and explain any of the above checked
Do you consider you to be in good health and able to participate in normal program activities? YesNo If no, please explain
To the best of my knowledge, this health history is correct In case of emergency, I give my permission to persons representing Girl Scouts of Colorado to see that I receive appropriate emergency medical or surgical treatment, and/or hospitalization if necessary. It is understood that every effort will be made to reach the person named above as my emergency contact.
I, being an adult over the age of 18 hereby consent that my name, image, and likeness, as shown in the video-tapes, photographs, motion picture film and/or electronic images for which I posed, and/or audio recordings made of my voice may be used by Girl Scouts of the U.S.A., its assigns or successors, in whatever way they desire, including television and Web sites; furthermore, I hereby consent that such photographs, films, recordings, electronic images, and the plates, tapes and/or software from which they are made shall be their sole property, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, recordings, electronic images, plates, tapes and software as they may desire free and clear of any claim whatsoever on my part
Signature to indicate you agree to the terms and conditions. Date Signed
$50.00 – $275.00Price range: $50.00 through $275.00
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3-Day Paddler Camp, 5-Day Sports Sampler Camp, Program Aide, Tag-a-long
