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Get Girl Scout Medical Form

EN COMPLETED. PRINT CLEARLY, USE BLACK INK.) Girl's Name Troop/Group # Home Address Phone ( City Date of Birth ) State Zip Date of last Health Exam Girl's Physician/Clinic Phone ( Parent/Legal Guardian Phone ( Cell Phone ( ) ) ) HOSPITAL INSURANCE INFORMATION Attach photocopy of insurance card. Name of Carrier Policy # Insured's name Member ID# Company name if insured through employer Phone: ( ) Others who could be contacted to authorize treatments: Name Day( ) Evn( ) R.

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