Individual Girl Registration Form Page 2

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#realtalkgs2016
Saturday, August 27, 2016
Individual Girl Registration Form
Cost: $35 per person • $40 after July 15
Registration deadline: Sunday, August 14 • Registration questions:
To register online:
To register by fax: (619) 795-6930
To register by mail: Girl Scouts, 1231 Upas St., San Diego, CA 92103
For general information contact Steph Dawes at (619) 610-0772 or e-mail:
Name ___________________________________________________________________________________________________________________
Mailing Address ____________________________________________________ City__________________________________ Zip _____________
E-mail __________________________________________________________________________________________________________________
Phone (day) (_____________)________________________________ Phone (evening) (_____________)_______________________________
I give my permission to have photographs and/or video taken for publicity purposes.
Accommodations needed, if any (accessibility, medical, dietary, interpreter, etc.) ______________________________________________
Lunch Options:
Dinner Options:
Turkey Sandwich
Roast Beef Sandwich
Veggie Sandwich
Chicken
Vegetarian
For additional dietary requirements please email or call (619) 610-0771
I will attend:
#realtalkgs
Adult celebration
Girl evening component
.
You can stick to one bucket or mix and match sessions for a day of work and play
Session
Bucket List
Bucket Quest
Share Your Bucket
9:45-11 a.m.
The Road to College
Dare Greatly
To Infinity and Beyond
12:15-1:30 p.m.
Gold Award Info Session
Inside Out
Stop. Collaborate. And Listen.
2-3:15 p.m.
Career Roundtable
Adventure is out there!
Improv Yourself
I have read the program details and give my child permission to participate in the activity listed above. I understand that I am responsible for arranging transportation to and
from event location, unless a transportation option is listed in event details. I understand that in case of emergency, every effort will be made to contact a parent/guardian prior
to medical treatment. If the parent/guardian cannot be reached, however, and the situation requires immediate emergency attention as determined by the Girl Scout
representatives, I hereby authorize representative of Girl Scouts San Diego to obtain necessary treatment for my daughter.
Yes
No
I give permission for photographs, videos, audio recording, and quotations of my child taken by authorized Girl Scouts San Diego staff or
their designee to be used for council publications, television, or the World Wide Web.
Yes
No
Signature of Parent/Guardian
_______________________________________________________________________ Date ________________________________
Real Talk Teen
Cost for conference:
$35
A Girl Should Be Two Things
T-Shirt
Cost for girl evening component/adult celebration:
$10
T-Shirt $17.01
This flowy scoop neck tee has
a subtle curved hem. Made of
I am requesting financial assistance in the amount of $___________.
a poly-viscose blend, this tee
is very soft. Regularly priced
Please make checks payable to Girl Scouts.
at $21, you save 25% when you
purchase with registration and
Credit card, complete the following:
American Express
Visa
MasterCard
Discover
pick-up at the event.
Sizes small through 2XL
Amount to be charged $___________ Real Talk Teen T-Shirt $___________ Size ______
$17.01 ($15.75 plus tax)
Credit Card Number ______________________________________________ Exp. Date_____________ Date _____________________________
Print Name ______________________________________________________ Signature ________________________________________________
Return completed form and payment
DELIVER/DROP-OFF
MAIL
QUESTIONS? Email
FAX 619-795-6930 Attn: Customer Care
GSSD Balboa Campus
Girl Scouts San Diego
• GSSD cannot confirm receipt of FAX
Attn: Customer Care
Attn: Customer Care
• Do not mail original form once fax is sent
1231 Upas Street, San Diego, CA 92103
1231 Upas Street, San Diego, CA 92103
#RT 05/13/16

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