Republic of the Philippines

Department of Education
Region VII, Central Visayas
Division of Cebu City
Cebu City National Science High School
Salvador St., Labangon, Cebu City
GIRL SCOUTS OF THE PHILIPPINES (SCI-HI ANGELS)
School Year 2022-2023

HEALTH EXAMINATION FORM

Name____________________________________________________ Birth Date _____________

Surname First Middle

Parent/Guardian ________________________ Phone _____________

HomeAddress_________________________________________________________
Street & Number Town/City Province
In case of emergency, notify _______________________ Phone __________________
Address____________________________________________________________________________
HEALTH HISTORY: ( check – giving approximate dates )
Frequent Colds________________ Kidney Trouble __ Chickenpox ________________
Abscessed Ears _________ Convulsion Mumps .
Fainting Sleepwalking Whooping Cough .
Frequent Sore Throats Measles .
Sinusitis Heart Trouble .
Bronchitis Rheumatic Fever .
Stomach Upset _____________ Athlete’s Foot .
Constipation Tuberculosis .
Operations or serious injuries Diabetes .
Allergic Reactions:
Penicillin Other Drugs .
Details of above or additional information
Any specific activities to be encouraged? .
Restricted? _______________________

IMPORTANT: Please notify the camp if this applicant is exposed to any communicable disease during
three weeks prior to camp attendance. ___

Suggestions from Parent/Guardian: .

_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
In case of Surgical emergency: I hereby give
permission to the physician selected by the
camp director to hospitalize, secure prior
treatment for and to order injection, anesthesia
or surgery for my daughter as named above.
Signature _____________________________
Date _________________________________

PHYSICAL EXAMINATION – to be filled out by licensed physician

CODE V – Satisfactory
X – Not Satisfactory (explain)

Height ________ Blood Pressure_________ Circulatory System___________Blood Analysis__________

Weight______________________________ Urinalysis
________________________________________
Eyes________________________________ Loco-motor System ________________________________
Eye glasses ___________________________ Nervous System __________________________________
Ears_________________________________Skin ____________________________________________
Nose ________________________________

Allergy – Please specify_________________________________________________________________

Throat_______________________________ _______________________________________
Teeth _______________________________ General Appraisal _________________________________
Heart Lungs __________________________ Menstrual history _________________________________
Abdomen ____________________________
 Genitalia ______________________
Kernia _______________________________

Recommendations and restrictions ( diet, medicine, swimming, diving, etc. )

_____________________________________________________________________________________
_____________________________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________

Immunizations

D.P.T.Series _________Booster _________ Date _________Tetanus Booster __________ Date _______

Typhoid series _______Booster _________ Date ___________
Small Pox _______________________________________ Date ________________________________

________________________________
Examining Physician

Telephone _____________________________ Address _______________________________________

Date __________________________________
 GIRLS SCOUTS OF THE PHILIPPINES
NATIONAL HEADQUARTERS
MANILA

APPLICATION FORM
(GIRL)

Event: _________________________________ Date: _________________________________

PERSONAL DATA:
Name:
______________________________________________________________________________
LAST MIDDLE FIRST
Date of Birth: _______________ Age: ___ Home Address: ______________________________
Troop Number: ___________ Council: ______________ Date of Last Registration: __________
Religious Affiliation: _________________Number of Years in Scouting: __________________
Campus/Special Events Attended:
Event Date
__________________________________ ________________________________
__________________________________ ________________________________
__________________________________ ________________________________
__________________________________ ________________________________

In emergency, please notify: ______________________ Relationship: ____________________

Address: __________________________ ___________ Telephone Number: _______________

PARENT’S CONSENT

This is to certify that I have given full consent for my daughter ____________________
_____________to participate at the _______________________________________________
_________________________________.

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.

I shall not hold the Girl Scouts of the Philippines or its representative responsible for any
untoward accident that may happen beyond their control. Her physical fitness is assured in a
medical examination.

____________________________ Signed: _____________________________________

Date Parent/Guardian