Fee-Funded Summer Day and Evening Camp Registration 2010

Day Camp Winona-Summer sessions-All Campers

Please, do Not <submit> more than 1 time. After pushing the <Submit Application> button you will see a white screen with the registration form ready for printing.  Print a copy for your records.  Do NOT mail this form as you will be registered 2 times.  Mail the fees (or use PayPal) and waivers to us, but NOT the next page. If corrections, use the "Change Data Form". 
If we don't have your camp fees and waivers, you are not completely registered.
Links to mail/pay are on camp registration page

Only accepting limited registrations, as most units are full.  Teen Aides (grade 8-12) are welcome.

We already have these Bus Stop Monitors at all stops except:  Still needed are Upper Marlboro Crossroads-Giant and Dent ES,
We need Bus Chaperones: parent to ride all buses.

Page 1 - Registration
 
*Camp Name:         Session:                Camp Dates: 
Financial Assistance:  Are you applying for financial assistance?    Yes     No (skip below square)
For Financial Assistance, complete this section:  Camper's family will be responsible for at least 20% of camp fees.  If family can not pay this amount, ask your troop to see if they can help pay. (per Council 3/10/10)

Our family can pay  $.  Requested Amount  $   Please explain reason for need: 

Is she receiving Financial Assistance for another camp?  Yes     No   
If yes,   Sleep Away  Day Camp  -- Camp Name (s):

Has she attended a Girl Scout Camp in the past?   Yes     No  
If yes, camp name: 

 
 Camper Information
(Please see the samples to the right)

*First Name:

 (Legal name - Susan)

middle initial:

 *Last Name:

Informal Name:

 (informal- Susie) Optional
   

Sex:

*Camp Program:

  

Parent help at camp? (in a unit, center, or first aider)

 No    Yes  (If yes, please fill out the Adult Registration and Adult Health History forms)

If Aide or AIT, are you adding Teen Trek-White Water rafting

 No    Yes  (If yes, add $80 to fee. No service hours will be earned on Friday)
 

Program Aide and AIT are leadership programs designed for girls who have attended camp in the past and want to help plan camp and work with the younger girls.

Camp Fee:

 $ camp fees chart
   

*Address - Street/PO Box: 

*City:

*State:

 *Zip Code: 
 
*Mother/Guardian's Info

 Name:
 

E-Mail:

  
Be sure this is correct.  We send communication via email, including attachments.
 

*Day Phone:

 (000-000-0000)
 

Evening Phone:

  (000-000-0000)
 

Cell Phone:

  (000-000-0000)
 
*Father/Guardian's Info

Name:
 

E-Mail:
Be sure this is correct.  We send communication via email, including attachments.
  Day Phone:  (000-000-0000)
  Evening Phone:  (000-000-0000)
  Cell Phone: (000-000-0000)  
 
If divorced or separated, who has custody of the child?    
Other:
 
Emergency Contact Information
If parent/guardian cannot be reached, persons to notify in case of  emergency. (List at least one local contact that could pick up camper, if required).
*Name -1:
  *Relationship:
  *Day Phone:  (000-000-0000)
  Cell Phone:  (000-000-0000)
*Name -2:
  Relationship:
  Day Phone:   (000-000-0000)
  Cell Phone:   (000-000-0000)
 

Grade

in 2009-2010 School Year:

*Birth Date:

 (mm/dd/yyyy)(use /)

*Age as of  June

*Current School:

   Home Schooled

Location:
  Copy of vaccination record is required for person not enrolled in a Maryland public or
private school (ex. home school or one in another state).  If required, send copy to registrar with fees.
 
*Transportation:  Some stops only for summer camp.
 Bus is recommended over carpooling
If carpooling or plan to have some one pickup your child, give name/s here:
Only those listed will be authorized to pick up your child.  Give name, not just parent or sister, etc
 
Note: We cannot have a bus route or bus stop without a bus monitor or stop chaperone.  Thank you for helping to keep our girls safe.
 I would like to serve as a Bus Stop Monitor at stop (take attendance and insure girls' safety at bus stop)
AM/PM Bus Stop Monitor
Bus Chaperone - I would like to serve as a Bus Chaperone.  Person rides bus starting at end stop. Good opportunity to help without driving daily.
 

*Currently registered Girl Scout? No    Yes

 (If no, add $12 to camp fee)
    If yes,  Troop #:       Level:
GS Buddy or Non-GS friend name:   
Only submit one name at same level/grade and program.   We try, but do not guarantee buddy placement!
 
*T-shirt size:     T-shirt size chart (no shirt given to teen trek trips)
 
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 summary reports we send at end of camp.
*The registrant's racial background  is  
     If Other, specify:           
*The registrant's Ethnic background is:              
Campers in grades K-6, skip below box.
If AIT or Teen Aide/Staff position, please give us your choices:
Assignment Preference 1st Choice

 
Assignment Preference 2nd Choice

 
Assignment Preference 3rd Choice

 
                    Other idea?  List:      
Teen Tuesday after camp special activities (vote for 1): 
Swimming (indoor or out) movie  Calvert Marine Museum & boat ride  ice skating
 
I have completed the following Training: 
     I have the Cadette PA Pin     I have the Senior PA Pin     I completed day camp Aide-In-Training (AIT)
     I am a BS       I have been to a GS day camp before, either as a camper or a teen aide
     I have no experience/not a GS and would like to do this for high school service hours
 

Parent/Guardian Permission Statements

Check all that apply for your camper.  If Not checked and initialed, we assume no permission and camper will NOT participate in activity.  Person will stay at camp in a different unit for the time, or parent will be called to pick up.  All activities are subject to volunteer availability.

Some activities are considered high risk by GSUSA Safety-Wise standards and require parent initials. 
 All Campers and Camps Check permissions and Initial as applies:

    * Swimming ability (required for all aquatic activities):  
 none    Level 1    Level 2    Level 3   Level 4   Level 5   Level 6   
Red Cross Water Safety, or catalog with levels starting on pg 6

Campers SUMMER - 6-12 grades for swimming. 

Swimming - If available, I give permission for person herein described to participate in swimming at camp.  Lifeguards may give water test for pool use at site, and may or may not be Girl Scouts - Lackey HS pool in spring; outdoor pool in summer for teens only.
Parent Initials (high risk) 
Ice Skating - If available, I give permission for person herein described to go ice skating at Capital Clubhouse rink in Waldorf.  A school bus will take girls to/from activity site.
Parent Initials (high risk)  

Dinner Theater - (grades 4-12)-June 25 I give permission for person herein described to participate in the dinner theater event at Toby's Dinner Theatre in Columbia, MD. Musical show is "Hairspray".  Buffet brunch will be served prior to show. (NOTE: extra fees apply that are not part of regular camp fee, with after camp return bus and 1 stop per county.)
Parent Initials

Campers in 2-12 grades-SUMMER only:
 

Paddle boating -  I give permission for person herein described to participate in paddle boating at camp, if available. Personal Floatation Device (PFD) will be worn at all times. An adult or teen aide will be in the boat with younger girls.
Parent Initials (high risk)

Campers in 4-12 grades-SUMMER only:
 

Archery - If available, I give permission for person herein described to participate in Archery. 
Parent Initials (high risk) 

Horse Riding - (Junior Wrangler,Teen Adventure-1 units) I give permission for person herein described to travel to A Moment in Time horse farm via school bus for horse riding/activities.  (Winona 1 Aides and AITs in Junior Wrangler units, if riding horse with assigned unit. No service hours will be earned).
Horse Release/Waiver is required. 
Parent Initials (high risk)

Mail/email vendor horse waiver to camp Registrar with camp fee.
Campers in 6-12 grades-SUMMER only. (Girls also check swimming permission above, if rafting)

White Water Rafting - (Teen Adventure-2 units, Winona 1 Aides and AITs only.) I give permission for person herein described to participate in the white water rafting event on the Shenandoah and Potomac Rivers.  Class 1-III rapids.  Person will bring a bagged lunch and drink to eat before going on the river.  Helmets will be supplied by the outfitter. (Aides and AITs If attend, no service hours will be earned during event.) This is a high risk activity per Safety Wise.  Different bus on trip day to leave earlier and come back later with 1 stop per county only. (NOTE: extra fees apply that are not part of regular camp fee for Aides/AITS.)
Parent Initials (high risk)

Mail/email vendor rafting waiver to camp Registrar with camp fee.

Bowling - If available, I give permission for person herein described to participate in Bowling in Waldorf.  A school bus will take girls to/from activity site.
Parent Initials (high risk) 

Museum - If available, (Teen Adventure-1 & 2 units) I give permission for person herein described to visit a museum, Calvert Marine Museum in Solomons, MD.  An hour boat ride will be included in the trip.  A school bus will take girls to/from activity site.
Parent Initials (high risk) 

Late Afternoon, evening activity - (all summer teens) -  I give permission for person herein described to stay for early evening activities. Activity will be swimming in the NAS Patuxent River base outdoor swimming pool.  If teen goes swimming, it is considered high risk by GSUSA Safety-Wise standards, and permissions must be checked above. Parent pick-up after activity is over in the evening is required at only Wildewood shopping Center, Mattawoman-Beantown Rd park and ride, and Upper Marlboro Crossroads Giant.
Parent Initials

ALL:

The health history below is correct so far as I know, and the person herein described has my permission to participate in all prescribed camp activities as noted. (including crafts, games, hikes, outdoor skills, cookout).  If she/he appears to be ill, I will not send her/him to the program

Emergency Authorization: I hereby give permission to the medical personnel selected by the camp director or her/his designee to order x-rays, routine tests and treatment for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director or her/his designee to hospitalize, secure proper treatment for, and/or order injection and/or anesthesia and/or surgery for my child as named above.

Yes  No   The Council may use any photo in which my child appears to promote Girl Scouting.
I understand my daughter will become a registered member of Girl Scouts of the USA through participation in this program.
 
*Electronic Signature of Parent/Guardian giving permissions checked above:                             
Who will be signing the registration form?  Parent     Guardian
*Council permits Electronic signature.  Registration is invalid without a parent/guarding signature.

Page 2 - Health History
Allergies?  Check all that apply, giving descriptions.
  Insect Bite/Sting Allergies?  Hay Fever
  Plant (Ivy, Oak, etc.) Allergies?  Other Allergies? 
  Specify any accommodations that are needed:
 
Food Allergies and Dietary Restrictions:
  Vegetarian Vegan
  Kosher Halal
  Allergy Other
  Please specify any accommodations that are needed:

 
 
Health Concerns
Ear Infections Asthma     
Diabetes Convulsions    
Skin conditions Bedwetting    
Sleep Disorder Other    
       
Please specify any accommodations required:
   
Disabilities
ADD/ADHD Emotional Disability  Learning Disability
Physical Disability Visual Disability Deaf/Hard of Hearing
Behavioral Problems Other
Please specify any accommodations required:
 
Operations or serious injuries?
 
                    
Operation Dates
 
 
Immunization History:
Are all immunizations up to date?  Yes     No

*Date of last Tetanus shot (DTP or DT):   (mm/dd/yyyy)

If immunizations are not up to date, including the DTP, please submit a state certificate from physician or parent
stating medical or religious reason.
If your child is under 5 years old or is not currently in school full time, please attach a copy of his/her
immunization record. 
 
Medication Information: 
If your child requires medication at event/camp (prescription, over-the-counter medication, Epi-Pen or inhaler), please complete the Medication Permission Form located on the Council website: http://www.gscnc.org/camping/summerdayandevening/l
Note:  Medication CANNOT be administered at camp without the submission of this form or an appropriate substitute.
 General Information:  

Doctor/Physician:

Doctor Phone:

   (000-000-0000)
 Insurance Info  

Health Insurance Company:

Policy Number:

Company Street:

City:

     

State: 

    Zip Code

 

Print the form on the next page for your records; do not mail it to camp Registrar. Follow instructions for payment on next pages.