Form M-67 - Intent To Operate A Service Unit Program Event Form
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1Girl Scouts of Silver Sage
1410 Etheridge Lane
INTENT TO OPERATE A
Boise, ID 83704
(208) 377-2011 or (800) 846-0079
SERVICE UNIT PROGRAM EVENT
FAX (208) 377-0504
Service Unit Planning the Event______
Is this event a money-earning activity? Yes No
Person in Charge
Date
Name/ Position
Mailing/Physical Address
City
State
ZIP Code
Phone
Event Information
Event Name/Description_________________________________________________________________________________
Summary of Activities___________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Event Date, Time, Location______________________________________________________________________________
Please attach a flyer for council review.
Is this event open to other Service Units?
___Yes
___No
Will Cookie Dough be accepted as payment? ___Yes
___No
If yes, please state that on the flyer. Complete a Cookie Dough Reimbursement Request following the event.
Projected Number of Participants -- Girl Scouts___
Non-Girl Scout Girls___
Adults___
Adults needed to meet Adult-to-Girl Ratio_______
Our First-Aider is ___________________________________________________
(Attach copy of current CPR/FA certification card for your First-Aider and any additional safety certifications required for
your event based on Safety Checkpoints.)
Event Planning Checklist:
We plan to engage girls in program event planning and implementation.
We have created a detailed project plan and budget for the event.
We will incorporate the Girl Scout Leadership Experience elements in the program event design.
We will have a first-aid kit on hand.
We will make alternate plans should weather be an issue.
All adults in charge are familiar with and will abide by the safety information provided in the Safety-Wise chapter of the
Volunteer Essentials Handbook.
If any Safety Activity Checkpoints apply to our event, we have listed the checkpoints on the back of this form along with
additional Safety Checkpoints we will adhere to.
We have obtained Plan 2 insurance, if applicable.
Authorization
Service Unit Event Coordinator Signature
Date
Service Unit Manager Signature
Date
Volunteer Support Team Signature
Date
Forward completed form to the Volunteer Support Team at the Girl Scout office.
M-67 (8/2012)
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