Trip Activity Permission Form printable pdf download

Trip Activity Permission Form

Up To 3 Days and 2 Nights * Including Camping Trips

Complete and submit to Membership Specialist or District Director at least 2 weeks prior to any trip.

Approval or request for additional information will be sent via Email. Please keep a copy for your records.

Group/Troop # __ __ __ __ __ Volunteer Name_______________________ Grade Level (circle one): D Br Jr Cd Sr Am

Adult TRIP Volunteer's Name __________________________________ Phone (H) ________________________________

Address ____________________________________________________ Phone (C) ________________________________

City ________________________________ State ________ Zip ____________ Email ______________________________

Destination __________________________ Departure Date ________________ Return Date _________________________

Number Attending: Registered Girls ______ Registered Adults ______________Non-registered Participants_____________

(Supplementary insurance must be purchased from the District Office for non- registered participants and trips longer

than 3 days and 2 nights.)

Emergency Contact Person at Home_____________________________________________________________________

Phone (H) __________________________ (W) ___________________________ (Cell) __________________________

When preparing for any activity with girls, always begin with the Safety Activity Checkpoints written specifically for

each activity(s) the group participates in and Volunteer Essentials.

Planning Checklist:

Safety Activity Checkpoints is used for all activity planning ()

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Volunteer Essentials is also used for planning ()

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If leasing or renting a vehicle, all rental contracts must be authorized by the CEO of Girl Scouts—Dakota Horizons.

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NOTE: 15 passenger vans are not approved for travel.

All drivers are licensed, insured, at least 18 years of age and must be a registered adult Girl Scout.

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Certificate of insurance on leased or rented vehicle must be sent to District Office prior to departure date.

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All girls and adults are registered with GSUSA or purchase additional insurance to cover non-registered members.

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Trip Coordinator will carry signed health/permission cards for all girls at all times (Volunteer Essentials page 47).

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Appropriate girl/adult ratios are met at all times (Volunteer Essentials page 6 and page 44).

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Appropriate and safe equipment will be used at all times in accordance with the Safety Activity Checkpoints.

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Location and emergency phone numbers of nearest hospital will be on hand (Volunteer Essentials page 50).

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A First Aid kit is available. 1

Aider Name_________________________ Type of First Aid certificate__________

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A certified lifeguard has been secured for water activities. Lifeguard Name _________________________________

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Emergency Contact Person has a list of all participants, their emergency phone numbers, Council Emergency Procedures

Card and trip itinerary.

Attach the following documentation to this form and send to your District Director:

Contact Information – name, address, phone and emergency contact for each girl and adult participant.

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Itinerary – include all dates, destinations, and departure and arrival times.

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Transportation – car, van, train, plane, etc, for each destination.

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Lodging/Destinations – name, address, phone and contact information for all destinations and lodging.

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SE District

District

NW District

NE District

1101 S. Marion Rd

1202 E St Francis

735 Airport Rd

OR 525 31

Ave SW

1002 43

St S OR 2525 Demers Ave

Sioux Falls, SD 57106

Rapid City, SD 57701 Bismarck, ND 58504

Minot, ND 58701

Fargo, ND 58103 Grand Forks, ND 58201

Fax 605-336-6841

Fax 605-343-9508

Fax 701-223-7840

Fax 701-838-1574

Fax 701-293-7962 Fax 701-772-6670

OFFICE USE ONLY

Trip Approval

HAS or HAS NOT been granted.

Reasons or Comments _____________________________________________________________________________________________________________________

District Director Signature ____________________________________________________________________________________

Date _______________________

Revised 10/15/12

Trip Activity Permission Form

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