Forms
2014 Resident camp individual registration form
Name of parent/guardian___________________________________________________________________________________ Home phone _______________________Work phone_________________________ Cell phone________________________ Email address______________________________________ Address________________________________________________ City____________________________________________ State________ County__________________ ZIP_________________ Emergency contact: Name___________________________________________________________ Relationship_____________________________ Primary phone____________________________________Secondary phone_______________________________________ My daughter is under the custodial care of:
q Both parents q Mother only q Father only q Other _______________________________________________ Camper’s name_____________________________________________________________ Birth date_____________________ Grade in fall_______________________________ Shirt size (specify youth or adult size)______________________________ Parent permission: I give my daughter, ________________________________, permission to participate in all phases of the Girl Scouts of Central Indiana day camp program. I understand the arrangements as stated in the camp information. I will not allow her to attend camp if she has been exposed to any contagious disease, and will notify the camp director if this is the case. In an emergency, when neither I nor the emergency contact person named can be reached, I hereby authorize the camp director to take any action deemed necessary for the best interests of my daughter. I understand that part of the learning experience of day camp is living with peers; therefore, there is no visitation during sessions. I give permission for out of day camp travel when it is part of the day camp program. I give permission for all photos and videos of my daughter at day camp to be used for public relations purposes for Girl Scouts of Central Indiana. Signature of parent/guardian______________________________________________________ Date____________________
Are you currently a registered member of Girl Scouts of Central Indiana?
Program Assistance Grant (PAG) information
q Yes, troop #___________ Service unit______________
If yes, include PAG application and $10 deposit.
Is financial assistance needed? q Yes q No
q Yes, Juliette (individual Girl Scout) q No, non-Girl Scout
Name of only one friend that you want in your unit
Out of council
Requests must be mutual! Request for more than
Council name____________________________________
one buddy and requests that go in a circle will not be
Additional information
honored.
(optional for statistical purposes only)
Last_______________________ First____________________
Camper’s racial background
Grade in fall _______________________________________
q American Indian or Alaskan Native
Special needs
q Black or African American
This includes religious, dietary, mental, physical, and emotional needs. q Yes q No
q Hawaiian or Pacific Islander q White
If yes, please elaborate______________________________
q Other (Specify________________________________)
__________________________________________________
Camper’s ethnic background
q Hispanic or Latina q Not Hispanic or Latina
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