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Registration Form

RESIDENT CAMP REGISTRATION FORM

This form can be photo copied. Submit one form per camper OR register online at www.girlscoutsni.org. Registration opens February 12, 2013.

PLEASE PRINT: Camper Name ________________________________________________________________________________________ Address _________________________________________ City ________________________ State/Zip _____________ Home Phone _________________________ Troop #_____________ OR Member not in troop _____________ Girl’s Date of Birth _____ /_____ /_____ Age ________ Grade (Fall 2013) _______ T-shirt size (Camp Dean Day Camp Only): YS_____ YM_____ YL_____ AS_____ AM_____ AL_____ AXL _____ Parent/Guardian _________________________ Day Phone _________________________ Relationship _______ Parent/Guardian _________________________ Day Phone _________________________ Relationship _______ Contact E-mail _______________________________________________________________________________________ EMERGENCY INFORMATION: Parents/guardians—If you cannot be reached in case of an emergency, please list the name of a friend or relative who will be able to contact you. Name __________________________________________________ Relationship _________________________________________ Day Phone __________________________________________ Evening Phone _________________________________________ BUDDY INFORMATION: My camper would like to be in the same session as: (List only ONE BUDDY and make sure the friend is attending the same session and that she indicates your camper’s name as a buddy reference on her application. Submit both applications together.) _______________________________________________________________________ List all sessions for which you are registering. If attending more than 3 sessions, use an additional form. PLEASE PRINT

PROGRAM NAME

CAMP NAME

SESSION DATES

SESSION FEE

AMOUNT PAYING AT THIS TIME*

1st session 2nd session 3rd session Girl Scout registration fee (due only if your camper is not currently a Girl Scout) $12** TOTAL AMOUNT ENCLOSED *IMPORTANT: A $50 deposit is required for each session. If a deposit is not included, registration WILL NOT be processed. Deposit is refundable ONLY if the session is not available. The only exception are those applying for Title XX Grants—no deposit is required. (See page 4 for Title XX information.) PAYMENT INFORMATION: Form of payment : (Please indicate amount of each applicable type.) _______ Cash _______ Check/Money Order _______ Credit Card _______ Cookie Dough (Not for deposit) CREDIT CARD TYPE: _______ VISA _______ MasterCard _______ Discover Expires _______________________ Cardholder’s Name (PRINTED) ____________________________________ Signature _______________________________________________ Cardholder’s Address _________________________________________________ City/Zip _______________________________________________ Card # _____________________________________________________________________________________ Validation Code ___________________

Three numbers on back of card in signature box.

**My camper is not currently a registered Girl Scout. I have included a $12 membership fee and understand this registers my camper as a Girl Scout through 9/30/2013. This membership fee is non-refundable. OFFICE USE ONLY Amount Received $ ___________________ Date ___________________ Payment processed by ______________________________________ Entered in Personify by ___________________________________________________________________________ Date _________________________

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Media Permission: When participating in Girl Scout activities, I may be photographed for print, videotaped, or electronically imaged. Images may be used in promotional materials, news releases, and other published formats for either the local Girl Scout Councils or Girl Scouts of the USA. The images will be the sole property of either the local or USA councils. Check here if you wish to opt out at this time. �

2013 GSNI Camp Program  

2013 GSNI Camp Program

2013 GSNI Camp Program  

2013 GSNI Camp Program

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