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American heritage girls
American Heritage Girls, Inc.
Health and Medical History Form
This form is valid for 12 months
Member Name: _________________________________________ Troop # _________________
_____/_____/_____ Age: ________ Weight___________
Custodial parent/guardian: __________________________________________________________
Home address: ____________________________________________________________________
City: _____________________________________ State: ________ Zip Code:___________
Home phone: _________________________ Work/cell phone: _____________________________
If parent/guardian above cannot be reached in the event of an emergency, notify:
Member does not have health care coverage at this time
Member has health care coverage as listed below
Insurance Provider ________________________________________________________________
Address _______________________________________________ Phone # __________________
Policy Holder _____________________________________ Policy #_______________________
Group # __________________________________________ Effective Date __________________
Primary Care Physician _____________________________________________________________
Physician’s address:_________________________________________ Phone #: ________________
Dentist’s Address:__________________________________________ Phone #:________________
Please list all known allergies including those to medications, food and environment. If none known, please write “none known”. Attach additional page to this form if needed. Allergy to:
Normal reaction and management of the reaction
GENERAL HEALTH INFORMATION:
(Please circle all items that apply, past or present,
to your health history. Explain all “Yes” answers.)
Explain any “YES” answers:
Year primary series completed
Oral Polio___________________ __________________
Tetanus Shot_________________ __________________
Year last given:________ Result:_________
Please include all medications the participant is currently taking. If these medications need to be administered during an AHG event,
the Request for Medication Administration form must be completed.
Date of last physical examination:___________________________
Over the Counter, As Needed Medications
The following are OTC medications that may be available at AHG functions on an as-needed basis. Please consult with your
physician and indicate which medications the participant may receive.
OTC drug name
(generic may be used.)
I give permission for the medication indicated above to be given to my child (or self if an adult participant) if needed.
Signature of Parent/Guardian or Adult
Use this space to provide any additional information about the participant’s behavior and physical, emotional or mental
health needs pertinent to his/her participation in the American Heritage Girls program.
I give permission for full participation in American Heritage Girls programs, subject to limitations noted herein.
This health history is correct and complete, as far as I know. I hereby give permission for AHG leadership to administer
prescribed and noted over the counter medications. In case of emergency,
I understand every effort will be made to contact me (if participant is an adult, my spouse or next of kin).
In the event that I cannot be reached, I hereby give my permission to the licensed health-care provider selected by the adult leader
in charge to secure proper treatment, including related transportation, hospitalization, anesthesia, surgery, or injections of
medication for my child (or for me, if member is an adult), except as noted. I agree to the release of records necessary for treatment. Notes: _________________________________________________________________________________________
Date _________Signature of parent/guardian or adult ____________________________________________________________ I do NOT give my consent for medical treatment of my child (or for me, if member is an adult). In the event of illness or injury requiring treatment, I wish AHG leadership to take NO action beyond basic first-aid measures.
Date ________ Signature of parent/guardian or adult _____________________________________________________________
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