Page 7

___________________________________________________________________________________ ADDRESS ________________________________________________________________________________________________ E-MAIL ADDRESS _________________________________________ PHONE _______________________________________ ADULT CONTACT NAME

EMERGENCY INFORMATION: In case of emergency, please list a friend or relative who will not be at the camp. NAME _________________________________________________ RELATIONSHIP

___________________________________ DAY PHONE _________________________________________ EVENING PHONE ____________________________________ FAMILY MEMBERS ATTENDING PROGRAM: Please read program description for details on who can attend. Write adult or age of the child. Name

_____________________________________ _____________________________________ _____________________________________ _____________________________________

Relationship

Adult/Child(Age)

Sex

Registered GS

____________ ____________ ____________ ____________

____________ ____________ ____________ ____________

M/F

Y/N

M/F

Y/N

M/F

Y/N

M/F

Y/N

Mark Choice

Session

Camp

Dates

Fee per Person

CD46

Special Guy Overnight

Camp Dean

7/12-7/13

$30

CD26

Me & My Gal Overnight

Camp Dean

6/28-6/29

$30

CFH35

Family Fun Weekend

Camp Far Horizons

7/5-7/7

$50

CM27

Me & My Gal Overnight

Camp McCormick

7/19-7/20

$30

Please note: Total payment is due at time of registration

Number of people

TOTAL Amount Enclosed:

Total Due

Family Camping Registration Form

Please use this form for programs pertaining to Family Camping and mail to: GSNI, Elgin Service Center, 12N124 Coombs Rd., Elgin, IL 60124. Family Camp registration is NOT available online.

$

PAYMENT INFORMATION: Form of payment : (Please indicate amount of each applicable type.) _______ Cash

_______ Check/Money Order

CREDIT CARD TYPE:

_______ VISA

_______ Credit Card _______ MasterCard

_______ Cookie Dough (Not for deposit) _______ Discover

Expires ____________________________

Cardholder’s Name (PRINTED) ________________________________________ Signature _______________________________________________ Cardholder’s Address _____________________________________________________ City/Zip _______________________________________________ Card # _________________________________________________________________________________________ Validation Code ___________________

Three numbers on back of card in signature box.

OFFICE USE ONLY Amount Received $ ___________________ Date ___________________ Payment processed by ____________________________________ Entered in Personify by ______________________________________________________________________ Date ____________________________ 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. �

7

2013 GSNI Camp Program  

2013 GSNI Camp Program

2013 GSNI Camp Program  

2013 GSNI Camp Program

Advertisement