Junior Councilwide Camp

Form No. 1

INDIVIDUAL HEALTH APPLICATION FORM FOR GIRLS

PERSONAL DATA :
1. Name ___
Last Middle First
2. Date of Birth: Day Month Year Age Civil Status
3. Home Address : Tel. No.
4. School Address: Year
5. Person to notify in case of Emergency:
Name Relationship
Address Tel. No.
6. Religious Affiliation :
7. Food Prohibition :

Noted:

__________________________ Applicant’s Signature

Troop Leader

Date
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PARENT’S CONSENT FORM

TO WHOM IT MAY CONCERN:

This is to permit my daughter (Name) __ to

participate in JUNIOR COUNCILWIDE CAMP of Girl Scouts of the Philippines – Gensan Council.
To be held at Romana C. Acharon Central Elementary School on April 29-30, 2023.

We will not hold the Girl Scouts of the Philippines responsible for any untoward
incidents that may happen beyond their control.

__________
Date
Parents Signature

MEDICAL CERTIFICATE

I HEREBY CERTIFY that I personally examined the above-named applicant and have found out
that the she is physically fit to undergo scouting activities in attending the JUNIO COUNCILWIDE
CAMP to be held at Romana C. Acharon Central Elementary School on April 29-30, 2023.

REMARKS:
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________

____________________ _____________________ _______________

Physician’s Signature License # Expiration Date

ENDORSED:
________________________________ ____________________________
School/Coordinator/District Field Adviser School Principal/Head