Lawrence County Girl Scouts Present Camp Like A Girl! Day Camp 2017 When: June 19 23, 2017 Where: Camp Agawam Who: All Girl Scouts K 12 Time: 9AM 3PM Daily Cost: $75 for week full of fun Registration Deadline: May 31, 2017 Please complete one registration for each Girl Scout you are registering for Day Camp. All attendees must be paid members for 2016 17 year with GSWPA before they may register for Day Camp. There is no additional cost for Bussing or for the Overnight. Only girls entering grade 5 and older in the fall of 2017 may register for the overnight experience. We will make our best attempt to honor a buddy request, as long as the buddy is the same scout level. Program Aides (must still register by deadline) and Adult Volunteers No Charge for the week! The registration deadline is FIRM! All registrations must be mailed to Janet Kelly PO Box 567 Wampum, PA 16157. All checks must be made payable to GSWPA. All adult volunteers must be registered Girl Scouts with clearances on file with GSWPA. Any Volunteer meeting this criterion who wishes to help at camp should contact Colonel K at 724 944 5296 for information on Day Camp training and our tagalong unit. Day Camp 2017 Registration Must include a current GSWPA Health History Scout s Name: : Are you a trained Program Aide? NO YES Date of training: School and Troop Number Grade in Fall 2017 Buddy request: T Shirt Size (circle one): Youth: S M L XL Adult: S M L XL XXL Bus Stop Locations (Check only one): Wayne Township Fire Hall Forbush Custard Stand Shenango Fire hall Pulaski Township Building Wilmington High School Plain Grove Presbyterian Church Mohawk High School Westgate Plaza YMCA (parking lot West Washington Street) Pizza Joes Croton I will be dropping off and picking up my Scout daily Overnight Experience: (Must be entering grade 5 or older to participate) I will be attending the Overnight June 21 22. Contact information: Parent/Guardian Name: Phone Number: A Confirmation packet that includes a snapshot of the week s activities, lunch menu, packing list, and unit assignment, along with pick up/drop off times for bus stops, will be mailed on June 2. Please let us know how you would like to receive this: Mail to Girl s address list above Mail to alternate address (provide) Email to
Girl Health History Form GENERAL INFORMATION Girl s Name Birth Date / / Parent/Guardian (1) Name E-mail Phone Alt. Phone Parent/Guardian (2) Name E-mail Phone Alt. Phone Emergency Contact (Other than Parent) Relationship Phone Alt. Phone Custodial Care Mother Father Both Other If other, please describe: DROP OFF AND PICK UP INFORMATION Indicate in the space below the name of any person, including yourself, who is allowed to drop off and/or pick up your daughter at any Girl Scouting activity, including troop meetings, programs, camp, etc. Name Relationship Drop Off Pick Up Both INSURANCE INFORMATION Carrier Name Member Services Phone ID Number Group Number Primary Care Physician Primary Care Physician Phone HEALTH CONDITIONS Allergy Reaction Treatment Date of Last Reaction? Indicate in the space below any medical conditions (e.g., asthma, diabetes) that your daughter has. Is there a specific dietary regiment to follow? (If Yes, please provide details below.)
Girl Health History Form RECORD OF IMMUNIZATION Date of last Tetanus vaccine / / Select one of the following: I attest that all of the attendee s immunizations, as required for school, are up to date. Girl member has not received immunizations. Note: Please contact CustomerCare@gswpa.org to obtain and complete an immunization waiver. The waiver is required for participation. MEDICATIONS A qualified Health Care Professional (RN, LPN, DMD, or MD) or a PA Medication Administration certified approved volunteer may administer medications to participants. Arrangements between parents/caregivers and GSWPA Approved Volunteer for all medications dispensed must include: 1. Prescription and over-the-counter medications must be provided in their original container. 2. Prescription medications must contain the physician prescribed orders, including instructions. 3. Both prescription and over-the-counter medications must be given to the Approved Volunteer or First Aider/Health Care Professional. 4. Some Life threatening conditions will require medications to be carried and secured by the participant, girl or adult, and are approved for carrying in first aid kits. These include: Epi-pens needed for insect stings or serious food allergies, asthma inhalers, and items needed for diabetic and seizure emergencies. Prescription Medication: In the space below, please list any prescription medication that your daughter is required to take, including any selfadministered emergency medication such as an Epinephrine injector or rescue inhaler. Medication Purpose Self-Administer? Over-the-Counter Medication: In the list below, please select any over-the-counter medication that your daughter is NOT permitted to take. Ibuprofen Calamine Lotion Liquid Tears Anti-fungal Cream Aloe Vera Cough Drops Menstrual Cramp Relief Antacid Bacitracin (i.e. Neosporin) Dramamine Expectorant Acetaminophen Antihistamine Antidiarrheal Decongestant Other SIGNATURE Please select the checkbox and sign and date this form: Permission to Provide Necessary Treatment or Emergency Care: I hereby give my permission to medical personnel selected by Girl Scouts Western Pennsylvania to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me or my child. In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by Girl Scouts Western Pennsylvania to secure and administer treatment, including hospitalization for the person named above. This health history form is complete to the best of my knowledge, and the person herein described has permission to engage in all program activities, except as noted. This completed form may be photocopied. Permission to Self-Administer Medication: I confirm that my daughter has the knowledge and skills to safely have readily available (carry or possess outside of the regular supervision of the troop leader/first aider) and self-administer the indicated emergency medication as medically necessary at Girl Scout activities. The troop leader/first aider will be notified if they have to use their medication. Parent/Guardian Signature Date / /
Adult Health History Form GENERAL INFORMATION Adult s Name Birth Date / / Emergency Contact Information (First/Last name) Relationship Phone Alt. Phone Carrier Name Member Services Phone Primary Care Physician INSURANCE INFORMATION ID Number Group Number Primary Care Physician Phone HEALTH CONDITIONS Allergy Reaction Treatment Date of Last Reaction? Indicate in the space below any medical conditions (e.g., asthma, diabetes) that you have. Is there a specific dietary regiment to follow? (If Yes, please provide details below.) Date of last Tetanus vaccine / / Select one of the following: I attest that all of my immunizations are up to date. RECORD OF IMMUNIZATION I attest that I have not received immunizations. Note: Please contact CustomerCare@gswpa.org to obtain and complete an immunization waiver. The waiver is required for participation.
Adult Health History Form MEDICATIONS A qualified Health Care Professional (RN, LPN, DMD, or MD) or a PA Medication Administration certified approved volunteer may administer medications to participants. Arrangements between participants and GSWPA Approved Volunteers for all medications dispensed must include: 1. Prescription and over-the-counter medications must be provided in their original container. 2. Prescription medications must contain the physician prescribed orders, including instructions. 3. Both prescription and over-the-counter medications must be given to the Approved Volunteer or First Aider/Health Care Professional. 4. Some Life threatening conditions will require medications to be carried and secured by the participant, girl or adult, and are approved for carrying in first aid kits. These include: Epi-pens needed for insect stings or serious food allergies, asthma inhalers, and items needed for diabetic and seizure emergencies. Prescription Medication: In the space below, please list any prescription medication that you are required to take, including any self-administered emergency medication such as an Epinephrine injector or rescue inhaler. Medication Purpose Self-Administer? Over-the-Counter Medication: In the list below, please select any over-the-counter medication that you are NOT permitted to take. Ibuprofen Calamine Lotion Liquid Tears Anti-fungal Cream Aloe Vera Cough Drops Menstrual Cramp Relief Antacid Bacitracin (i.e. Neosporin) Dramamine Expectorant Acetaminophen Antihistamine Antidiarrheal Decongestant Other SIGNATURE Please select the checkbox and sign and date this form: Permission to Provide Necessary Treatment or Emergency Care: I hereby give my permission to medical personnel selected by Girl Scouts Western Pennsylvania to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me. In the event that my emergency contact cannot be reached, I hereby give my permission to the physician selected by Girl Scouts Western Pennsylvania to secure and administer treatment, including hospitalization for myself. This health history form is complete to the best of my knowledge, and I am permitted to engage in all program activities, except as noted. This completed form may be photocopied. Permission to Self-Administer Medication: I confirm that I have the knowledge to self-administer the indicated emergency medication as medically necessary at Girl Scout activities. The troop leader/first aider will be notified if I have used my medication. Signature Date / /