Girl Participant Information Form

To be filled out by the parent/legal guardian of each girl attendee

Contact Information

Girl:

Girl First Name:

Girl Last Name:

Girl Email Address (optional):

Grade Level Now:

Parent/Guardian #1:

First Name:

Last Name:

Primary Phone:         Secondary Phone (optional):

Email address:

Parent/Guardian #2:

First Name:

Last Name:

Primary Phone:         Secondary Phone (optional):

Email address (optional):

Emergency Contact

First Name:

Last Name:

Primary Phone:         Secondary Phone (optional):

Relationship:

Jubilation Information

T-Shirt Size:

Photo Release: GSSSC may use photos of my girl.         GSSSC may not use photos of my girl.

My girl and I have read and my girl will abide by the Behavior Agreement.

Does your girl have any special accessabiltiy needs? If yes, please briefly explain:

Older Girl Program Options

Each older girl attending Jubilation can choose which program they would like to participate in.

See Program Descriptions for more information.

Which day activity would you like to do?
White Water Rafting Excursion (Additional $10 needed)
Thousand Springs Geothermal Excursion

Which Friday night activity would you like to do?
Fright Night Ghost Tours of Old Twin
Starburst Campfire for older girls

Health History and Medical Information

Name of Family Physician:         Phone:

Family Medical/Hospital Insurance Carrier:         Policy or Group #:

Family Dental Insurance Carrier:         Policy or Group #:

Age: Weight:         Immunizations up to date: Yes   No   N/A         Date of last tetanus shot:

Date of last health examination:       Were there any problems at the time?

Has the participant had any recent injuries or surgery? Yes   No   If yes, please explain and specify date:

Is participant restricted or limited from participating in any physical activity?
          Yes   No   If yes, please explain:

Participant has the following health conditions:
ADHD/ADD   Asthma   Diabetes   Headaches   Seizures   Other:  

Allergies and treatments:

Over-the-Counter Medications Stocked at Jubilation

Indicate which of the following over-the-counter medications may be given to your girl by an Adult Leader or Camp Medical Staff. The examples given are not necessarialy the brand that will be given, but are merely provided to assist you in choosing.

Please do not send any of the following over-the-counter medications with your girl, as they will be stocked at Jubilation.

Yes   No   Decongestant (Sudafed, Actifed, etc.)
Yes   No   Acetaminophen (Tylenol, etc.)
Yes   No   Sore Throat (Halls, Sucrets etc)
Yes   No   Ibuprofen (Advil, Motrin, etc.)
Yes   No   Antacid (Tums, Rolaids, etc)
Yes   No   Antihistimine (Benadryl, Dimetapp, Claritin, etc.)

Note: If your girl requires any over-the-counter medications not listed here, indicate them in the chart below.

Medication Coming From Home
  • You must list all prescriptions and medications that your girl will be taking.
  • All girl medication MUST be turned in to the leader, and the leader will then turn medication over to the nurse to dispense during the event.
  • Medication MUST be in its original container with a non-expired original label.

MEDICATION INFORMATION

DOSAGE

1st

2nd

3rd

4th

Name of Medication:

Reason taking:

Adverse Affects Girl has Experienced:

How Long Girl has Taken:

Special Instructions:

When:

Quantity:

Form:

When:

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Name of Medication:

Reason taking:

Adverse Affects Girl has Experienced:

How Long Girl has Taken:

Special Instructions:

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Name of Medication:

Reason taking:

Adverse Affects Girl has Experienced:

How Long Girl has Taken:

Special Instructions:

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Name of Medication:

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Adverse Affects Girl has Experienced:

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