Individual Girl Leadership Opportunity Registration Form

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INDIVIDUAL gIrL LeADershIp opportUNIty regIstrAtIoN Form
Please PRINT legibly. Complete one registration for each opportunity.
Date Stamp
Please complete and return to: Girl Scouts of Gulfcoast Florida, Inc.
4780 Cattlemen Road • Sarasota, FL 34233 • 941-921-5358 or 800-232-4475 • FAX: 941-923-5241
All opportunity fees must be paid in full and attached to registration.
Title of Event _____________________________________________________________________________________________
Date(s) ________________________________________ Location _________________________________________________
Girl’s name: First _________________________ Middle ______________________ Last _______________________________
Currently registered Girl Scout Pathway # _____________
New Girl Scout
(Must completely fill out form and submit $12 registration fee)
Address ____________________________________________________ City _________________ State ______ Zip ________
Date of birth _____/_____/________ Age ______ Current grade ______ Name of school _______________________________
Custodial care of: (check one )
Both parents
Mother only
Father only
Other (specify) _______________________
Parent/guardian name: First _______________________ Middle __________________ Last ____________________________
Address (if different from child) _________________________________________ City _____________ State ____ Zip _______
Phone# (day) ________________________ Phone# (evening) ________________________ Cell# ________________________
Email (confirmations sent via email) ______________________________________________
Please mail my confirmation
Employer __________________________________________________________ Employer phone _______________________
Emergency contact: (other than parent/guardian)
First _______________________________ Middle _________________________ Last ________________________________
Phone# (day) ________________________ Phone# (evening) ________________________ Cell# ________________________
Grade Level: (check one )
K-1 (Daisy)
2-3 (Brownie)
4-5 (Junior)
6-8 (Cadette)
9-10 (Senior)
11-12 (Ambassador)
Is parent attending opportunity?
Yes
No
Name of adult attending ____________________________________________
Total per girl: $________ (event and registration fees - if applicable)
Total per adult: $________
Amount Enclosed $________
Method of payment: (check one ) - Must be paid in full
Cash
Check #_______________
Money Order
Charge Card (fill out information below)
Credit card information:
Please charge my:
MasterCard
Visa
Discover
Amount to be charged $___________ Credit Card # ___________________________________ Expiration Date _____/________
Print name as it appears on card _________________________________ Signature _______________________________
If you do not attend opportunity, you must cancel in writing by the deadline or forfeit the fee.
No refunds will be issued for cancellations after the deadline.
We acknowledge that the registrant will make the Girl Scout Promise and accept the Girl Scout Law and has our permission to join
Girl Scouts if not already a member. The registrant has our permission to participate in the event and its activities. The registrant
is in good physical condition/health and has undergone a physical within the last two years with no serious illness or operation
since. We understand that when participating in Girl Scout activities the registrant may be photographed for print, video, or
electronic imaging. We understand the images may be used in promotional materials, news releases, and other published formats
either for the local Girl Scout councils or Girl Scouts of the USA. We acknowledge that the images will be the sole property of
either the local Girl Scout council or Girl Scouts of the USA.
Date_____/_____/___________ Parent/Guardian Signature _______________________________________________________
We encourage you voluntarily to provide the following information on racial background and ethnicity. This information will be
used by Girl Scouts of Gulfcoast Florida, Inc. to help improve outreach efforts and advance the Girl Scout Movement.
The participant’s racial background is: (please check as many as apply)
American Indian or Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Other (specify __________________________)
The participant's ethnic background is: (please check one)
Hispanic or Latina
Not Hispanic or Latina
C:SHELF FORMS/2011Forms/IndividualGirlLeadershipOpportunityRegistration Form - Rev. 6/11

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