GIRLSCOUT OF THE PHILIPPINES

BASISTA NATIONAL HIGH SCHOOL

BASISTA, PANGASINAN

PARENTS/ GUARDIAN CONSENT FORM

This is to permit/ allow my daughter ___________________________________of

BASISTA NATIONAL HIGH SCHOOL to attend the Junior Saranay, Senior and Cadet

saranay Camp & Thinking Day Celebration 2019 I have considered the benefits that

my daughter will derive from her participation in this activity with the understanding

that every precaution is to be taken to ensure her safety in this activity.

I shall not hold the Girl Scouts of the Philippines or its representative

responsible for any untoward accident that may happen beyond their control.

__________________________
Signature of parent/ guardian
Overprinted name

Date signed: ____________________________

 GIRLSCOUT OF THE PHILIPPINES
BASISTA NATIONAL HIGH SCHOOL
BASISTA, PANGASINAN

HEALTH EXAMINATION FORM

NAME: _______________________________________________

Health History:
(check giving approximate dates)
Frequent colds: _____________________________________________________
Kidney trouble: _____________________________________________________
Chicken pox: _______________________________________________________

Abscessed ears:
_____________________________________________________
Convulsions: _______________________________________________________
Mumps: ____________________________________________________________
Fainting: ___________________________________________________________
Sleep walking: ______________________________________________________
Whooping cough: ___________________________________________________
Frequent sore throat: ________________________________________________
Measles: ___________________________________________________________
Sinusitis: ___________________________________________________________
Heart troubles: ______________________________________________________
Bronchitis: _________________________________________________________
Stomach upsets: ____________________________________________________
Rheumatic fever: ____________________________________________________
Constipation: _______________________________________________________
Tuberculosis: _______________________________________________________
Operations or serious injuries: ________________________________________
Allergic reaction: ____________________________________________________
Penicillin: __________________________________________________________
Other drugs: (specify): _______________________________________________
Details of the above or additional info:
___________________________________________________________________
___________________________________________________________________

Any specific activities to be encourage?

___________________________________________________________________

Restriction: _________________________________________________________
Please notify the camp if this restriction is exposed to any communicable
disease prior to camp attendance.
___________________
Licensed physician