TROOP REGISTRATION FOR TEEN EVENT

After completing this on-line Registration, mail Payment to
Michelle Acosta; (adress on confirmation page)
Girls 11-17 are welcome to attend.  Parents should not drop off girls, but should stay with them or
allow girl to join with a troop for the evening.

This is an Individual Registration    Troop Registration     CASP3R home

Part 1 - Registration
All - Basic Information

First Name:

 (Legal name - Kathleen)

Middle Name:

Last Name:

Event Fee:

 $ (add $12 for GSUSA girl registration, if not already)

Sex:

      Girl      Adult 
   

Address - Street/PO Box: 

City:

State:

 Zip Code: 
   
Transportation  
Parent Information  (If adult, Go to continue)
Mother/Guardian's  

First Name:

Middle Name:

 (required only if new to Girl Scouts)

Last Name:
 

E-Mail:
Be sure this is correct.  We send communication via email, including attachments.
 

Day Phone:

 (000-000-0000)
  Eve Phone:  (000-000-0000)
  Cell Phone:  (000-000-0000)
 
Father/Guardian's  
First Name:

Middle Name:

 (required only if new to Girl Scouts)

Last Name:
   
  E-Mail:
Be sure this is correct.  We send communication via email, including attachments.
  Day Phone:  (000-000-0000)
  Eve Phone:  (000-000-0000)
  Cell Phone: (000-000-0000)  
 
Who has custody of the child?    Other:
Birth date:  (mm/dd/yyyy)(use /)
Current School Grade: 
Age as of event Sept: 
Buddy name:  if coming with a friend
All, continue
Are you currently a registered Girl Scout?  
 Yes   Troop Number:           Program level: 
 No   Would you like to find out about Girl Scouting in your neighborhood?Yes  No                   
We encourage you voluntarily to provide the following information on racial background and ethnicity.  This information will be used by Girl Scouts of the USA to help improve outreach efforts and advance the Girl Scout Movement. This data does not affect placement at camp.  Council also requires this data on reports we send at end of event.
 Racial Breakdown   If Other, specify:  
                                                     
         Ethnic background is:  Neither Hispanic nor Latino      Yes Hispanic or Latino         
 

Part 2 - Health History
All attending should complete
Emergency Contact Information
If parent/guardian (or adult emergency contact) cannot be reached, persons to notify in case of  emergency. A minimum of one local emergency contact is required.
Point of Contact #1
  First Name:
  Last Name:
  Relationship:
  Day Phone:  (000-000-0000)
  Eve Phone:  (000-000-0000)
  Cell Phone:  (000-000-0000)
Point of Contact #2
 

Name:
  Relationship:
  Day Phone:   (000-000-0000)
  Eve Phone:   (000-000-0000)
  Cell Phone:   (000-000-0000)

Health History
Any medications brought must must be in the original container with person's name on the label.
Allergies?     None   
  Describe allergies where applicable:
Specific information including physical, psychiatric or behavioral problems? Please explain
 
Special dietary needs/restrictions.  Please describe:
Are all immunizations up to date?  Yes     No - If not, please state reason:
 Other Info:

Doctor/Physician:

Doctor Phone:

 (000-000-0000)  
 Insurance Info  

Health Insurance Company:

Policy Number:

Policy Holder Name:
 
Additional Medical Comments:
 

Parent Permission Statement

  • This health history is correct so far as I know, and the person herein described has my permission to engage in all event activities except as noted.  If she appears ill, I will not send her. 
  • EMERGENCY AUTHORIZATION: In the event I cannot be reached in an emergency, I hereby grand permission to the program director to secure proper treatment for my child.
  • The Girl Scouts may use any photo in which my child appears to promote Girl Scouting. 
  • If not already registered, I understand my daughter will become a registered member of Girl Scouts of the USA through participation in this program.

Signature of Parent/Guardian OR Adult registering:
(//name//) Date