Form 585f - Request For Approval Of Day Or Overnight Activity/trip Requiring Council Permission - Girl Scouts Of Eastern Oklahoma

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GIRL SCOUTS OF EASTERN OKLAHOMA
REQUEST FOR APPROVAL OF ACTIVITY REQUIRING COUNCIL PERMISSION
FORM IS DUE FOUR (4) WEEKS IN ADVANCE
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Send to: 4810 S. 129
E. Ave., Tulsa, 74134
If you expect tagalongs,
Troop # __________ Troop Level __________ Service Unit __________________________
please specify:
Leader _________________________________ Email ______________________________
# of Girls and their ages:
Phone (H) ________________ Phone (W) ________________ Phone (C) _______________
# of Boys and their ages:
Address ______________________________ City ____________________ Zip __________
You must provide extra adult(s),
in addition to the girl/adult ratio,
#Girls ________ #Female Adults ________ #Male Adults ________ #Tagalongs _______*
who will be responsible for
* See box at right for further information about Tagalongs
tagalongs.
FIRST AIDER (Required for all activities):
Activity Begins (Location) __________________________
Name: ___________________________________________
Certification Type: _________________________________
At (Time): _____________ On (Date): _______________
Issued by (GSEOK, ARC, AHA, etc.): _________________
Traveling to: _____________________________________
Expiration Date: ___________________________________
Activity Ends (Location) ____________________________
At (Time): _____________ On (Date): _______________
OR - Medical License (MD, RN, LPN, EMT, etc.)
Complete ONLY if using a COUNCIL FACILITY:
Type & Number: _______________Expiration Date: _______
Check-in Time __________
Check-out Time __________
NOTE: Wilderness First Aid or Wilderness First Responder is
Date __________
Date __________
required if EMS response is more than 30 minutes.
Note: If using a council facility, identify by camp AND unit
MODE OF TRANSPORTATION:
(i.e.-Tallchief Bunkhouse)
 Private Vehicle
 Public Transportation
 Rental/Charter *
 Loaned Vehicle *
 Locked Facility (Motel, private home, etc.) or any Council
* Submit Form #589F
Facility. Specify: ___________________________________
AT-HOME CONTACT (NOT accompanying the troop):
 Unlocked Facility (tents, etc.) Rating Score _________ **
NAME: __________________________________________
Specify type of facility: ______________________
HOME PHONE: ___________________________________
**COMPLETE THE SECURITY RATINGS FORM
CELL PHONE: ____________________________________
(#588F OR #597F) TO DETERMINE SCORE
LEADER’S STATEMENT OF COMPLIANCE
 Safety Activity Checkpoints, Volunteer Essentials, GSEOK’s Position Statement on Safety and Security Form #590T and/or
Emergency Procedures Form #579T have been reviewed and are being adhered to.
 I have verified that all personnel (first aider, lifeguard, instructors, etc.) are currently certified to perform in those capacities
according to safety guidelines.
 I have verified that all drivers for this activity are properly licensed and that the vehicle they will be driving is registered, insured
for liability (as required by Oklahoma statutes) and well maintained. Every passenger will have a seat and use a seat belt.
 Parents have been informed of the particulars regarding this activity including safety precautions/emergency procedures.
Permission will be received for each girl with parent or guardian signature acknowledging their understanding of and agreement
with the activity(s) as planned and that they have no further questions.
LEADER’S SIGNATURE ________________________________________________
DATE ____________________________
Complete the information on the back for planned activities requiring approval, including camping.
#585F 06/16

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