Buion Clothra Guides

CATHOLIC GUIDES OF IRELAND

(ANNUAL MEDICAL FORM)

NAME OF BRIGIN GUIDE / GUIDE / RANGER GUIDE:

TEL NO:

Home:

Mobile:

ADDRESS:

DATE OF BIRTH:

UNIT:  Buion Clothra Guides

GUIDER:  

NAME AND ADDRESS OF OWN DOCTOR:

TEL NO:

HAS YOU 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/tetanus etc.)?

PLEASE LIST ANY DISABILITIES YOUR DAUGHTER MAY HAVE (physical or medical e.g., epilepsy, Asthma etc.):

IS YOUR DAUGHTER HAVING ANY MEDICAL TREATMENT AT PRESENT?  IF SO, PLEASE GIVE DETAILS OF MEDICATION WHICH SHE MAY BE ON:

Please only list regular medication – e.g. Inhalers.

This information will be requested again for camp so that we have up to date information.

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