Catholic Guides of Ireland (Standard Health Form) Event:
NAME OF BRIGIN/GUIDE/RANGER GUIDE: TEL NO: DATE OF BIRTH:
ADDRESS: UNIT: GUIDER:
NAME AND ADDRESS OF OWN DOCTOR: Tel No:
HAS YOUR DAUGHTER BEEN IN CONTACT WITH ANY INFECTIOUS DISEASES WITHIN THE LAST MONTH:(Please give details)
IS YOUR DAUGHTER ALLERGIC TO ANYTHING: (e.g. penicillin, aspirin, etc)
PLEASE LIST ANY DISABILITIES YOUR DAUGHTER MAY HAVE: (physical or medical e.g. Asthma)
IS YOUR DAUGHTER HAVING ANY MEDICAL TREATMENT AT PRESENT IF SO, PLEASE GIVE DETAILS OF MEDICATION WHICH SHE MAY BE ON:
HAS YOUR DAUGHTER HAD AN ANTI TETANUS INJECTION, IF SO PLEASE GIVE DATE APPROXIMATELY OF LAST INJECTION:
EMERGENCY PERMISSION I hereby give my permission to the (Guider in Charge) ............... To sign for whatever medical/surgical treatment deemed necessary in an emergency for my daughter .................. Signature: ................... (Parent/Guardian) Date: ...................
DIETARY REQUIREMENTS DOES YOUR DAUGHTER REQUIRE SPECIAL FOODS OR SPECIAL PREPARATION OF FOOD FOR ANY MEDICAL CONDITION SHE MAY HAVE: (Please state medical condition and requirements e.g. celiac, diabetic) IS YOUR DAUGHTER VEGETARIAN: YES .......... NO ..........
PLEASE USE THIS SPACE FOR ANY FURTHER INFORMATION