Day Camp Camper Registration Form

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Day Camp Camper Registration
form #870 • 01/16 • page 1 of 1
A fully completed, signed registration packet must be accompanied by these 3 things: 1) Completed
“Day Camp Health History & OTC Medications”, 2) camp payment, and 3) PA/CIT Application (If
applicable). Send all to the address listed on your day camp information page. A completed regista-
tion packet does not guarantee camper placement. Contact the day camp registrar with questions.
DO NOT mail registrations to the Girl Scout service centers.
Day Camp _____________________________________ Camper Name _________________________________________________
Mailing Address __________________________________________City __________________________ State _____ ZIP _________
Guardian ___________________________________________ Buddy Name
(if applicable)
Age ______ DOB ____________ Grade Next Fall _______ School Next Fall _______________________________________________
Check how camper will be participating:
All girls attending day camp must be registered Girl Scouts for the current
membership year. If you will be paying for this membership by credit/debit card
Daisy (K-1)
Brownie (2-3)
Junior (4-5)
Cad (6)
or would like to apply for financial assistance the easiest way to register for
membership is online at!
Child of Camp Staff
Program Aide-In-Training
Program Aide
Parent/Guardian #1 (that lives with camper/same address)
My camper is a registered Girl Scout for the current membership year or I will
Name ______________________________ Cell # ( ____ )___________
register her online. I will pay the camp fee only.
Please register my camper as a Girl Scout. I will pay Girl Scout day camp fee +
Home # ( ______) ______________ Work # ( _____ ) _____________
$15.00 membership dues. This will register her as a Girl Scout through Sep-
tember 30 of this year.
Email _____________________________________________________
Acceptance and participation in summer programs is the same for everyone without
Parent/Guardian #2
regard to race, color or national origin. As an equal opportunity organization, Girl
Scouts is dedicated to diversity and fully supports the right of equal access for girl and
Name ______________________________ Cell # ( ____ )___________
adult members with disabilities. Girl Scouts of Oregon and Southwest Washington
makes every reasonable effort to ensure this access.
Home # ( ______) ______________ Work # ( _____ ) _____________
We encourage you to voluntarily provide the following information on racial back-
Email _____________________________________________________
ground and ethnicity. This information will be used by Girl Scouts of the USA for
Emergency Contact (other than Parent/Guardian #1 or #2)
statistical purposes only and to help improve outreach efforts and advance the Girl
Scout Movement.
Name _______________________________ Relation ______________
The registrant’s racial background is (please check as many as apply)
American Indian or Alaskan Native
Home # ( ______) ______________ Work # ( _____ ) _____________
Black or African American
Optional Items (Your day camp may offer some or all of the follow-
Hawaiian or Pacific Islander
ing options. Please refer to their flyer for more information.)
Other. Please specify ______________________________________________
The registrant’s ethnic background is (please check one)
Try-It/Badge Choice (If applicable, see specific day camp
Hispanic or Latina
Not Hispanic or Latina
description. List in order of preference.)
Parent/Guardian Permission
1st choice _________________________________________________
As a legal guardian I give permission for the registrant to participate in all phases of
camp activities and off-site trips. I understand that it is my responsibility to inform
2nd choice ________________________________________________
the day camp of activities that my camper may not participate in. I understand and
agree to cooperate with all regulations. I will not allow registrant to attend if not in
3rd choice _________________________________________________
good physical condition. In an emergency, when the undersigned or other person
named cannot be reached, I give permission for the camp authorities to take any
Rainbow Program (last level completed, see specific day camp
emergency measure deemed appropriate. It is understood that all reasonable efforts
description for guidelines and availability of this option):
will be made to contact the parent/guardian.
I understand that when participating in Girl Scout activities the registrant may be
photographed for print, video or electronic imaging. I understand that the images
Overnight :
may be used in promotional and fund raising materials, news releases and other pub-
lished formats, and will be the sole property of Girl Scouts of Oregon and Southwest
Bus Stop (if applicable, see day camp description):
Washington, its assigns or successors, or Girl Scouts of the USA.
I wish to opt in to GSUSA/GSOSW
T-Shirt Size
May NOT be photographed for Girl Scout publicity purposes
X __________________________________________________________________
Signature of Parent or Guardian
Cookie/Nut Credits: Use this section to record your 19-digit
Cookie/Nut Credit card number and 8-digit PIN. Cookie/Nut
Credits may only be used by the girl who earned them.
I may be interested in helping at camp. Please contact me with information
on volunteer opportunities.
Amount to be used $ ____________________
card #


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