Cadette Troop 492
Emergency and Contact Information

Girl's Name: ________________________________  Date of Birth: __________________

Address:  _________________________________________________________________

Home Phone:  ___________________ Girls Email: ________________________________

School:  _________________________________________________________________

Physician: ________________________________ Phone Number: __________________



Mother: __________________________________________________________________

Cell Phone: _______________________  Alternate Phone:  ________________________

Email: ____________________________________________________________

Father: __________________________________________________________________

Cell Phone: _______________________  Alternate Phone: ________________________

Email: ____________________________________________________________


Emergency Contact (other than a parent - outside the home):

Name: ________________________________________  Phone: ___________________

Relationship to Girl Scout: __________________________________________________


Please list any medical conditions you want the troop leader(s) to be aware of,
including any allergies or medications taken on a regular basis:_____________________

_________________________________________________________________________

_________________________________________________________________________

For any known medical conditions or allergies, please list any specific actions the
troop leader(s) should take in case of an emergency:_____________________________

_________________________________________________________________________

_________________________________________________________________________

___________________________________                  _________________________
Parent Signature                                                                  Date