Specialty Camp Registration Form - Girl Scouts Of The Missouri Heartland
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1
2Girl Scout specialty camp registrations will be accepted starting on February 29, 2016.
Girl Scout specialty camp registrations will be accepted starting Feb. 2, 2015.
Specialty Camp Information
Event Name ___________________________________________ Option (if applicable) ___________
Date _____________ Location _________________________________________________________
Registration Information
5-Digit Troop/Group # ___________ Service Unit Number _________ County ____________________
Age Level □ Daisy
□ Brownie
□ Junior
□ Cadette
□ Senior
□ Ambassador
(K-1st)
(2nd-3rd)
(4th-5th)
(6th-8th)
(9th-10th)
(11th-12th)
Attending Adult Name (if required) ______________________________________________________
If adult attendance is required to meet girl-adult safety ratios, then the adult(s) with the group will be responsible for bringing a
signed parent permission and health history form for each girl attending, as per Girl Scout safety standards, and for keeping
the forms with them during the program.
Address ___________________________________ City ______________State _____ Zip ________
Phone _____________________ Email __________________________________________________
(Confirmations sent via email unless otherwise requested. Do not attend the program if you have not received a confirmation.)
Parent/Guardian Name (if different than above) ____________________________________________
Email Address ______________________________________________________________________
(Confirmations sent via email unless otherwise requested. Do not attend the program if you have not received a confirmation. )
Camp Fees (Check program description for pricing.)
# of girls attending:
_____
x cost per girl:
$ ______ =
Total girl fees:
$________
0
# of adults attending:
_____
x cost per adult:
$ ______ =
Total adult fees:
$________
0
# of girl/adult Girl Scout membership registrations: ______ x $15 =
Total fees:
$________
$ 15
0
Camp T-shirt
______ x $10 =
Total t-shirt fees:
$________
$ 10
(please circle sizes and quantities needed)
0
Sizes: YS
YM
YL
AS
AM
AL
AXL
A2XL
A3XL
A4XL
A5XL
d
$________
TOTAL GIRL AND ADULT FEES
0
Payment Methods
Cash
$________
Check(s), made payable to Girl Scouts of the Missouri Heartland, Inc.
$________
Cookie Credit (if applicable)
(Make sure to include 2-digit security code located on back of card).
Cookie Credit Gift Card # _____________________________ - ____________ - __ __
$________
Troop Bucks (if applicable)
(Make sure to include 2-digit security code located on back of card).
Troop Bucks Gift Card # _____________________________ - ____________ - __ __
$________
Financial Assistance Application for Program Activities
(Financial assistance form must be attached for each person requesting it.)
$________
Credit Card
$________
(Please complete information below.)
TOTAL ENCLOSED
$________
Credit Card Type: ___________
0
Card #: ______________________________ Expiration Date:________
Name on Card: _______________________ Signature: ________________________________
Trainings (Please check any that apply.)
□ CPR/First Aid Certified Name: __________________________ Phone: (____)__________
□ BOS Trained
Name: __________________________ Phone: (____)___________
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