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23 Council-Sponsored Trip Girl Medical/Permission Slip Girl Scouts of Southern Illinois My daughter has my permission to go on a councilsponsored trip to on (date). I understand that if my daughter does not conduct herself in a cooperative manner, making a good impression on herself, her troop and the Girl Scouts of Southern Illinois, she will be sent home on public transportation. The cost of the transportation for the return trip will be reimbursed to Girl Scouts of Southern Illinois Council by the parent. Medical information: Birth date: Age at time of trip: Name of Medication: Date to Start: Time Mediation Administered: Discontinue Date: Reason Medication is needed: Possible side effects: My daughter may administer this medication herself: Name of Medication: Date to Start: Time Mediation Administered: Discontinue Date: Reason Medication is needed: Possible side effects: My daughter may administer this medication herself: Name of Medication: Date to Start: Time Mediation Administered: Discontinue Date: Reason Medication is needed: Possible side effects: My daughter may administer this medication herself: I hearby give permission for the appointed adult by the council to administer the following over-the-counter medications if the First Aider deems it necessary. Dosages will be administered according to directions on the bottle unless a physician directs otherwise. Headache.Tylenol Upset Stomach... Pepto Bismol/Tums Diarrhea Immodium AD/other diarrhea medication Menstrual Cramps..Ibuprophen Poison Ivy/Insect Bite Calamine Lotion or CortAid/other anti-itch lotion 23

24 She is allergic to: (please list) She has a history of: She wears: contacts Glasses Braces Dentures Telephone and Name of private physician Health Insurance Company Number Employer of carrier Telephone number where parents may be reached: Day numbers: Evening numbers: Cell/pager numbers: Other people to contact (name, relationship, phone number): The undersigned, being parent or guardian of a minor, do hereby authorize and empower (name of appointed volunteers) Angie Zahn or Kim Lucy to act on my behalf in obtaining necessary medical treatment for the said minor. This authorization shall extend to obtaining ordinary medical treatment and, if deemed necessary by physician, emergency medical treatment including surgery, if such surgery is required in life-treating situation. In the event a physician recommends elective surgery, my express verbal approval is required. This authorization shall apply to medical treatment and services provided by any licensed physician or accredited hospital. Notary Information Subscribed and sworn to before me (Parent or guardian signature) This day of, 20 witness my hand and official seal. Notary Public My commission expires: My commission expires: 24

25 Girl Scouts of Southern Illinois Health History and Medical Examination Form for Adults Health History: The more complete information you provide, the better we are able to work with you to ensure you receive the care you need. Medical Examination: A medical examination is completed for trips lasting more than three nights. The examination is completed by a licensed physician, nurse practitioner, physician s assistant or registered nurse within the preceding 24 months unless a health issue is present. Please type or write clearly and legibly. Name of Adult: (Last, First, Middle Initial) Date of Birth: (XX/XX/XXXX) Sex: M F Address: City: St: Zip: Spouse (if applicable): Phone: Alternate Phone: Emergency Contact Information: Emergency Contact: Relationship: Phone: Alternate Phone: Health Insurance Information (Family insurance is primary insurance in case of accident or illness, Girl Scout insurance is secondary.) Policy Holder's Name: Policy Number: Insurance Company Name: Group Number: Insurance Company Address: Insurance Company Phone: 25

26 Check all that apply and explain in detail checked answers: Diabetes Heart Defects/Disease Asthma or Hay Fever Diseases of the Ears or Ear Infections Musculoskeletal Disorders Convulsions/Epilepsy/Seizures Sinusitis (Sinus Infections) Physical Restrictions Kidney/bladder illness Mental/psychological disorder Hypertension/Abnormal Blood Pressure Arthritis Nosebleeds Hernia Menstrual cramps Bleeding disorder Eyesight Impairment Hearing Impairment Speech Impairment Intestinal Disorders/Constipation Chicken Pox Measles German Measles Mumps Rheumatic Fever Tuberculosis Kidney Disease Eating Disorders (Anorexia, Bulimia, etc.) Headaches/Migraines Had surgery or hospitalized in the last 5 years Currently under doctor s care Other: Please explain in detail all checked answers marked above: Adult Name: 26

27 Allergies: Please list all allergies, the type of reaction and its severity, treatment and date of last reaction. Include allergies to medications, food, bees, animals, plants, etc Allergies Reaction/ Severity Treatment Date of last Reaction Do you suffer from Anaphylaxis? Yes No *Anaphylaxis is a severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing. Do you carry an Epipen? Yes No Do you carry an inhaler? Yes No Medical Conditions (including any precautions or restrictions on activities) Name of Condition Effects Medications: List any medications currently taken (or has taken in the recent past) including dosage schedule and specific instructions for use Medication Purpose Dosage Schedule Specific Instructions 27

28 Over-the-Counter Medications: In case of accident or injury. Please check all that apply: Tylenol/Acetaminophen Aspirin (fever reducer) Ibuprofen (pain/swelling) Benadryl/Antihistamine Robitussin/expectorant Sudafed/decongestant Pepto Bismol Tums/antacid Imodium (anti-diarrhea) Dramamine (motion sickness prevention) Skin Ointments (in case of rash, antibacterial, athlete s foot, etc.) Special considerations or notes regarding over-the-counter medications: Other: Other: Do you have a Special Medical or Dietary Regiment to be followed? Yes No If so, please explain: Have you ever had any adverse reactions to general anesthetics? Yes No If so, please explain: Additional information that is important for other advisors on this trip to know about: Adult Name: Date: (This section is to be completed by a physician after the review of health history. Adult must complete all the information in the Health History to the best of their knowledge and sign before meeting with licensed professional.) Medical Examination Height: Weight: Pulse Rate: B. P.: / Sugar: Albumin: Blood Hemoglobin: Hearing: R L Eyes: With Glasses R 20/ L 20/ Without Glasses R 20/ L 20/ Code: S = Satisfactory NS = Not Satisfactory NE = Not Examined 28

29 Does this applicant have any conditions which might limit activity for this event/travel/assignment; such as chronic disease, weight or limit participation in swimming or other strenuous activity? Yes No If yes, please explain: Record of Immunization Date Series Year of Date Series Year of was Completed Last Booster was Completed Last Booster Hep B DTap/Tdap DT/Td Hib IPV/OPV PCV7 Typhoid Paratyphoid Cholera Yellow Fever Typhus Rocky Mountain Physician Information Licensed Physician Name: (Last, First, Middle Initial) Phone Number: Address: City: St: Zip: This person is in satisfactory condition and may engage in all usual activities, including physically demanding activities except as noted. Signature of Licensed Physician: State License Number: Date: HEALTH INFORMATION PRIVACY STATEMENT The Adult Health History and Medical Examination Form is for health care concerns at the specified event only. All records will be handled by staff/volunteers whose job includes processing or using this information for the benefit of the participant. All medical records will be held in limited access by the health care supervisor for the specific event. Minimal necessary information may be shared with event staff/volunteers in order to provide adequate participant safety and health care. This form will be retained for seven years in the case of treatment. Access to the information will be limited, but copies may be requested from the event sponsor, by the participant or their legal representative. I have read the above procedures for handling the health and medical form and I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. This Adult Health History and Medical Examination Form is complete and accurate. Signature of Adult Participant: Date: 29

30 Girl Scouts of Southern Illinois Health History and Medical Examination Form for Minors Health History: The more complete information you provide, the better we are able to work with your child to ensure she receives the care she needs. Medical Examination: A medical examination is completed for trips lasting more than three nights. The examination is completed by a licensed physician, nurse practitioner, physician s assistant or registered nurse within the preceding 24 months unless a health issue is present. Please type or write clearly and legibly. Name of Minor: (Last, First, Middle Initial) Date of Birth: (XX/XX/XXXX) Address: City: St: Zip: Parent or Guardian: Phone: Alternate Phone: Parent or Guardian: Phone: Alternate Phone: Emergency Contact Information (parent/guardian): Emergency Contact: Relationship: Phone: Alternate Phone: Health Insurance Information (Family insurance is primary insurance in case of accident or illness, Girl Scout insurance is secondary.) Policy Holder's Name: Policy Number: Insurance Company Name: Group Number: Insurance Company Address: Insurance Company Phone: 30

31 Check all that apply and explain in detail checked answers: Diabetes Heart Defects/Disease Asthma Ear Infections Musculoskeletal Disorders Convulsions/Epilepsy/Seizures Sinusitis (Sinus Infections) Physical Restrictions Kidney/bladder illness Mental/psychological disorder Hypertension Arthritis Nosebleeds Has begun menstruation Menstrual cramps Bleeding disorder Sleep disturbances Fainting Bed wetting Constipation Chicken Pox Measles German Measles Mumps Rheumatic Fever Tuberculosis Kidney Disease Eating Disorders (Anorexia, Bulimia, etc.) Headaches/Migraines Had surgery or hospitalized in the last 5 years Currently under doctor s care Emotional Separation Anxiety Other: Please explain in detail all checked answers marked above: Girl Name: 31

32 Allergies: Please list all allergies, the type of reaction and its severity, treatment and date of last reaction. Include allergies to medications, food, bees, animals, plants, etc Allergies Reaction/ Severity Treatment Date of last Reaction Does your daughter suffer from Anaphylaxis? Yes No *Anaphylaxis is a severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing. Does your daughter carry an Epipen? Yes No Does your daughter carry an inhaler? Yes No Medical Conditions (including any precautions or restrictions on activities) Name of Condition Effects Medications: List any medications she is currently taken (or has taken in the recent past) including dosage schedule and specific instructions for use. Also, please indicate (Yes/No) if minor is allowed to take the medication on her own or if she should be monitored by an advisor. This would include any type of birth control Medication Purpose Dosage Schedule Specific Instructions Self-Medicate? (Yes/No) 32

33 Over-the-Counter Medications: My daughter has permission to take over-the-counter medications in case of accident or injury. Please check all that she has permission to take: Tylenol/Acetaminophen Aspirin (fever reducer) Ibuprofen (pain/swelling) Benadryl/Antihistamine Robitussin/expectorant Sudafed/decongestant Pepto Bismol Tums/antacid Imodium (anti-diarrhea) Dramamine (motion sickness prevention) Skin Ointments (in case of rash, antibacterial, athlete s foot, etc.) Other: Other: Special considerations or notes regarding over-the-counter medications: Does your child have a Special Medical or Dietary Regiment to be followed? Yes No If so, please explain: Have you ever had any adverse reactions to general anesthetics? Yes No If so, please explain: Any other information not covered in this form that is important that advisors for this trip know: Girl Name: Date: (This section is to be completed by a physician after the review of health history with parent/guardian. Parent/Guardian must complete all the information of the Health History to the best of their knowledge and sign before meeting with licensed professional.) Medical Examination Must be completed in detail. Height: Weight: B. P.: / Hearing: R L Eyes: With Glasses R 20/ L 20/ Without Glasses R 20/ L 20/ Code: S = Satisfactory NS = Not Satisfactory NE = Not Examined Nose Abdomen Urinalysis* Other: Throat Hernia HGB* Teeth Genitalia Appearance/Nutrition Heart Skin General Physical State Lungs Musculoskeletal General Emotional State 33

34 Record of Immunization Must be completed in detail. Date Series Year of Date Series Year of was Completed Last Booster was Completed Last Booster Hep B DTap/Tdap DT/Td Hib IPV/OPV PCV7 Typhoid Paratyphoid Cholera Yellow Fever Typhus Rocky Mountain Personal and religious beliefs dictate against immunizations: Yes No Physician Information Licensed Physician Name: (Last, First, Middle Initial) Phone Number: Address: City: St: Zip: This person is in satisfactory condition and may engage in all usual activities, including physically demanding activities except as noted. Signature of Licensed Physician: State License Number: Date: HEALTH INFORMATION PRIVACY STATEMENT The Health History and Medical Examination Form for Minors is for health care concerns at the specified event only. All records will be handled by staff/volunteers whose job includes processing or using this information for the benefit of the participant. All medical records will be held in limited access by the health care supervisor for the specific event. Minimal necessary information may be shared with event staff/volunteers in order to provide adequate participant safety and health care. This form will be retained for seven years past the age of maturity of the participant. Access to the information will be limited, but copies may be requested from the event sponsor, by the participant or their legal representative. I have read the above procedures for handling the health and medical form and I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. This Health History and Medical Examination Form for Minors is complete and accurate. My daughter has permission to engage in all prescribed activities, except as noted by me and the examining physician. Signature of Parent/Guardian: Date: 34

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36 Girl Scouts of Southern Illinois Adult Behavior Agreement for GSSI Extended Trip I understand that my attitude and behavior are critical to the success of the trip. Therefore, for the good of the trip as well as my fellow group members, I agree to abide by the following: 1. I will try to be sensitive to the needs of each group member. 2. I will respect the people and places with whom I come in contact. 3. I understand that the use of alcohol or drugs will not be tolerated, and that usage during the trip will result in expulsion from the trip. If I smoke tobacco, then I MUST do it away from the group and girls. 4. I will be responsible for my personal belongings and equipment and I will not hold the Girl Scouts of Southern Illinois responsible for their loss or damage due to my negligence or neglect. 5. I will treat all equipment (including hotel room) provided for my use with care. I understand that I will be assessed for damages to any equipment in the event that my use of such equipment is negligent or abusive. 6. I will use all required safety equipment and follow all safety rules and procedures but in place by GSUSA/GSSI. 7. I have read, understood, and will follow Volunteer Essentials and the Safety Activity Checkpoints regarding travel procedures. 8. I understand that I am a representative of the Girl Scouts of Southern Illinois and that if I am sent home early due to any serious misconduct, it will be at my expense and that the adult in charge of the event will make the travel arrangements and notify me of those plans. Participant s signature Date F: GSSI Forms/Program/Extended Trip/ Extended Trip Adult Behavior

37 Girl Scouts of Southern Illinois Girl Behavior Agreement for GSSI Extended Trip I understand that my attitude and behavior are critical to the success of the trip. Therefore, for the good of the trip as well as my fellow group members, I agree to abide by the following: 1. I will try to be sensitive to the needs of each group member. 2. I will respect the people and places with whom I come in contact. 3. I understand that the use of tobacco, alcohol, or drugs will not be tolerated, and that usage during the trip will result in expulsion from the trip. 4. I will be responsible for my personal belongings and equipment and I will not hold the Girl Scouts of Southern Illinois responsible for their loss or damage due to my negligence or neglect. 5. I will treat all equipment (including hotel room) provided for my use with care. I understand that I will be assessed for damages to any equipment in the event that my use of such equipment is negligent or abusive. 6. I will use all required safety equipment and follow safety rules and procedures. I have read, understood, and will follow Volunteer Essential and the Safety Activity Checkpoints regarding travel procedures. 7. I understand that I am a representative of the Girl Scouts of Southern Illinois and that if I am sent home early due to any serious misconduct, it will be at my parent s or guardian s expense and that the adult in charge of the event will make the travel arrangements and notify my parents/guardian of those plans. Participant s signature Date I understand and agree with the above responsibilities of my daughter. Parent s/guardian s Signature Date 37

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39 Girl Scouts of Southern Illinois Hired, Leased, or Rented Vehicle Log Vehicle VIN# (17 Digits) Year Make Model B=Bus V=Van A=Auto Cost of Hire Inclusive Dates of Hire From Through Certificate of insurance attached YES / NO Copy of Lease Agreement attached YES/NO Renter s Name Date Signature of Leaser Please Return to Property Director by September 1 of Current Year F: GSSI Fo 39

40 Girl Scouts of Southern Illinois 40

41 Intent to Travel - Extended Trip An Extended Trip is a trip of three or more nights excluding holidays. It is also a trip that exceeds 175 miles oneway of hometown. It is important to read the entire Extended Trip packet, Volunteer Essentials, and The Safety Activity Checkpoints before completing this form. Send the completed Intent to Travel form to your Service Unit Director and Girl Scouts of Southern Illinois Attention Extended Trip, #4 Ginger Creek Parkway, Glen Carbon, IL It is also important that you keep a copy of this form for yourself in your files. DEADLINE: Intent to Travel is due six (6) months in advance for trips inside the U.S.A. and sixteen (16) months in advance for trips outside the U.S.A. LEADER INFORMATION: Leader s Name Address City Zip Phone (D) (E) Leader s experience and training in preparation for this responsibility: TROOP INFORMATION: Troop # Service Unit Program Level Age of Girls Number of Girl Scouts Number of Girl Scouts attending trip Number of Adults Number of Adults attending trip Destination Travel Dates Total Number of Days 41

42 PROGRAM INFORMATION: List troop experience in planning activities, overnights, day trips, and previous extended trips: In preparation for the extended trip are the girls working on related badges or interest projects? Please list: What types of activities and/or tours is the troop planning on their extended trip? TRANSPORTATION INFORMATION: Method of transportation NOTE: All girls/adults must wear a seat belt. If leasing a vehicle you must complete the vehicle log form. The vehicle log form must be returned with evaluation upon returning home. PLANNING AND BUDGET INFORMATION: Currently the troop budget contains: $ We will have to earn $ Money-earning projects troop plans to use-list what the project is, when it is, and amount expected to earn: 42

43 NOTE: Troops must participate in the Cookie Program Sale in order to hold other money-earning projects. Approval for all money-earning projects must be obtained from your Service Unit Director. Troop s bank account location: Co-signers names and GENERAL INFORMATION: If your extended trip plans do not succeed, what is the troop s alternate plan to use funds collected? NOTE: If your plans change, submit another Intent to Travel form to your Service Unit Director and the Program Manager at the council office. If you cancel the trip, please inform your Service Unit Director and the Program Manager immediately! Leader s Signature Date Troop Secretary s Signature Date Service Unit Manager s Signature Date After the Intent to Travel form has been reviewed by the Program Manager, an initial approval letter will be sent to the leader. Once your troop has been granted initial approval you may begin earning money. Your Service Unit Director will also be notified of your approval and will be ready to review all your money-earning projects. Girl Scouts of Southern Illinois 43

44 Final Permit - Extended Trip It is important to re-read the entire Extended Trip packet, Volunteer Essentials and the Safety Activity Checkpoints before completing this form. Complete this form and mail it to your Service Unit Director and Girl Scouts of Southern Illinois, Attention Extended Trip, #4 Ginger Creek Parkway, Glen Carbon, IL Include with the form the following information: A detailed final itinerary. Complete list of girl and adult participants. Insurance coverage (Plan3E, 3P, 3PI) for Extended Trip and payment. Check may be addressed to GSSI. A copy of First Aid, CPR and Water-Safety Certifications. Copy of transportation insurance(s). Copies of drivers licenses and names of drivers, if applicable. Adult Behavior Agreement (one for each adult participant) Girl Behavior Agreement (One for each girl participant) Out-of-Council Trip Form. Copy of insurance forms for high-risk activities and lodging. DEADLINE: Final permit is due two (2) months before departure for trips inside the U.S.A. and three (3) months before departure for trips outside the U.S.A. LEADER INFORMATION: Leader s Name Address City Zip Phone (D) (E) Adult in Charge (if different) Phone (D) (E) First Aider Card Expiration Date Phone (D) (E) 44

45 TROOP INFORMATION: Troop # Service Unit Program Level Number of Girl Scouts Number of Adults Destination Travel Dates Total Number of Days Overnight Accommodations Meal Arrangements PROGRAM INFORMATION: Attach a detailed itinerary. Include the following information: Time of activities; rising and bed times; personal/rest times; addresses and phone numbers of places you will be staying; meal arrangements. On driving days, include mileage, to/from locations and number of predicted driving hours. TRANSPORTATION INFORMATION: Method of transportation NOTE: All girls/adults must wear a seat belt. If leasing a vehicle, the vehicle log form must be returned with evaluation upon returning home. Make and model of vehicle(s) License plate number(s) Owner(s) Name(s) Phone Seats with seat belts If renting/leasing a vehicle, what is the amount of the deductible on the policy? $ Has the rental contract been signed? 45

46 Attach all certificates of insurance for council review. Recommend limiting driving to six or seven hours of daylight driving per day. Make frequent stops and precautions to avoid fatigue for drivers and passengers. Names of licensed drivers, 18 years or older: (Include a copy of personal insurance information and driver licenses for each driver.) HEALTH/SAFETY INSURANCE AND INFORMATION: Complete and take the following forms on the trip! (You do NOT need to turn in a copy of these forms to council). Standard Health Examination Record Cards (girls and adults). Girls may use a copy of their current school health examination record. Notarized extended trip medical form for all girls and adults. Signed parent permission slip for each girl. GENERAL INFORMATION: In-town contact Phone (D) (E) Pager/Cell phone Address City Zip Person holding Lifeguard Certification (American Red Cross) Expiration date on card NOTE: If planning to use hotel/motel pools, troop must have a certified lifeguard. 46

47 BUDGET INFORMATION: Income: Cookie Sale $ Donations $ Money-earning projects 1. $ 2. $ 3. $ 4. $ 5. $ Miscellaneous $ Expenses: TOTAL INCOME: $ Food $ Transportation $ Insurance $ Lodging $ Equipment $ Supplies $ Miscellaneous $ Activities 1. $ 2. $ 3. $ 4. $ 5. $ TOTAL EXPENSES: $ In case of an accident or emergency, which may cause a deficit in the budget, what plans have been made? Are the girls contributing personal funds? If so, how much? $ 47

48 NOTE: If you plans change significantly after the final approval or you cancel your trip, please notify the Service Unit Director and the Program Manager immediately with changes to see if the trip is still approved. Leader s signature: Service Unit Director s signature: 48

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50 Name: Address: City: Zip: Troop #: Grade Level: Service Unit #: 50

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