CC Guiders

First Aid: Treatment Record

NAME OF CAMPER ________________________

UNIT _____________________________________

DATE_____________________________________

STATE THE FOLLOWING:

CONDITION ON ARRIVAL _________________________________________

_______________________________________________________________

_______________________________________________________________

TREATMENTS WHILE AT CAMP __________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

NAME OF CONSULTANT (DOCTOR, IF ANY) 

________________________________________DATE:__________________

HOSPITAL TREATMENT, IF ANY (IE EXRAYS, ETC.) 

________________________________________DATE: _________________

STATE PROVINCIAL HEALTH NUMBER ___________________________

PRINT NAME UNDER WHICH INSURANCE COVERED

_______________________________________________________________

IF NECESSARY, COMPLETE GIRL GUIDE INSURANCE PRELIMINARY NOTICE OF CLAIM FORM

 _______________________________________________________________

PARENT OR GUARDIAN NOTIFIED _______________________________

NURSES SIGNATURE______________________________________