Name: AHG Registration - Girl
SKU: 671
Availability: InStock

Description

Note to Parents and Guardians:
As part of the registration process, all of our troop leaders and volunteer adults have received a comprehensive background check ordered by Trail Life USA. They have also completed “Child Safety Youth Protection Training.” Both the background checks and training are repeated on a routine basis.

Additional information

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Troop NC-2913
Parent/Guardian Information
First Name (Parent) *
Last Name (Parent) *
Home Phone (Parent)
Cell Phone (Parent)

Child Information
First Name (Child) *
Last Name (Child) *
Date of Birth (Child) *
Age (Child) *
Weight (Child) *
Height (Child) *
Grade Completed (Child) *
Has your child been a member of any troop in the past? (Scouts, Trail Life, AHG, Etc.) *

Troop Meeting Permission Slip
Typical meeting time and place: Mondays from 6:30pm to 8:00pm 100 Southerland Rd. Clayton, NC 27527
Child can be released to the following people: *
As the parent/guardian I authorize my child to participate in Troop Meetings for the duration of the Program Year. *

Health and Medical Form
Primary Emergency Contact *
Primary Emergency Phone *
Relation To Child *
Secondary Emergency Contact *
Secondary Emergency Phone *
Relation To Child *
Please list all known allergies including those to medications, food and environment. Please include a normal reaction and management of reaction to know allergy. If none known, please write “none known”. *

General Health Information: Check all that apply past or present. Abdominal/stomach/digestive problems Asthma Convulsions/seizures COPD Diabetes Excessive fatigue Fainting or dizziness Head injury/concussion Heart disease/heart attack/chest pain/heartmurmur/coronary artery disease Hemophilia or blood disorders Hypertension (high blood pressure Kidney Disease Lung/respiratory disease Migraines/headaches Motion/altitude sickness Muscular/skeletal conditions/muscle or bone issues Neurological disorders Nosebleeds Sinus problems Sleep apnea, sleepwalking or sleep disorders Stroke/TIA Thyroid disease

Additional notes about the member’s behavior, physical, emotional or mental health needs.

Medications - list any medications that are regularly taken (including inhalers, Epi-Pens, over the counter medications, homeopathic, and prescription medications). Please include dosage information.

Has your child had a Tetanus Immunization within the last 10 years? *

The following are OTC medications that may be available at functions on an as-needed basis. Please consult with your physician and indicate which medications the child may receive. Check only those which are allowed. Benadryl Acetaminophen (Tylenol) Ibuprofen (Advil) Caladryl (Insect Bites) Hydrocortizone Cream (Plant Reactions) Chloraseptic (Sore Throat) Pepto Bismol Tums Peroxide (Cuts and Scrapes) Neosporin

This health history is correct and complete, as far as I know. I hereby give permission for the program leadership to administer prescribed and noted over the counter medications. In case of emergency, I understand every effort will be made to contact me. In the event that I cannot be reached, I hereby give my permission to the licensed health-care provider selected by the adult leader in charge to secure proper treatment, including related transportation, hospitalization, anesthesia, surgery, or injections of medication for my child, except as noted. I agree to the release of records necessary for treatment. *

Media Release
I authorize this release based on the following conditions: 1. These records become the property of Believers Baptist Church and its partners (IE. Trail Life USA and American Heritage Girls) 2. This release is given without promise of compensation 3. This is effective until terminated by a retraction in writing from the person granting the authorization 4. The parent/legal guardian and member do release to Believers Baptist Church and its partners any right, title and/or interest of any kind they may have in the records produced. I hereby grant to Believers Baptist Church and its partners the right and authority to photograph, film and/or record vocally. These records may be used for promotional or publicity purposes and may be published in mass media publications, in quarterly newsletter and other publications, on the internet, or shown on television or movie presentations. The member and family’s last name may be used. This release is effective until revoked in writing by the undersigned. Such revocation shall only be effective to prevent any expanded future use of the records. By signature below, I acknowledge and accept all terms and conditions of this Consent, Waiver, and Release Agreement. If I am signing this Consent, Waiver, and Release Agreement on behalf of a minor, I certify that all representations are true and that I am the minor’s legal guardian or custodial parent with full authority to bind the minor and myself to the terms and conditions of this Consent, Waiver, and Release Agreement.

Would you like to be a registered adult? * Unfortunately, I am not able to serve as a registered adult at this time. I understand that without being a registered adult, I cannot join meetings or outings that include children other than my own. Yes, I would like to be a registered adult. Yes, I would like to be an assistant leader. Yes, I would like to be a leader.

Believers Baptist Church

Imperfect people, risking it all, to love God,Love people, and make disciples.

AHG Registration – Girl

Troop NC-2913

Parent/Guardian Information

Child Information

Troop Meeting Permission Slip

Health and Medical Form

Media Release

Description

Additional information

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