3 minutes
To be eligible to fill out the Girl Scout Emergency Contact Form, you must be a girl Scout member.
Girl's name
Date of birth
Address
City
State/Province
Postal/Zipcode
Home phone number
Cell phone number
Is she allergic to any medications?
If YES,Please list:
Is she allergic to insect stings?
If YES,Please list:
Does she have any other allergies
If YES,Please list:
Are there any other medical conditions we need to be aware of?
If YES,Please list:
Emergency Contact person name
Relationship
Cell phone number
Signature
Date