Girl Scouts Of Southern Illinois Program Registration Form
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1
2PROGRAM REGISTRATION FORM
Girl Scouts of Southern Illinois
Corporate Service Center
Phone: 618.692.0692
#4 Ginger Creek Parkway
Fax: 618.692.0685
Glen Carbon, IL 62034
E-mail:
*All programs can be attended by troops OR individuals (unless otherwise stated)
PLEASE NOTE: Incomplete forms will not be processed.
Name of Event: __________________________________________________________ Deadline: _______________
Date of Event:
__________________________ Time of Event: __________________________________________
If choice of sessions, list:
1st: _________ 2nd: ___________ 3rd: ____________
Troop # _________
Service Unit ____________________________Girl Scout grade _____________________
Additional Information: ___________________________________________________________________________
Fees:
Total # of girls
______ X cost $ ______ = $ _______
Please provide girl info below
Total # of adults
______ X cost $ ______ = $ _______
Please provide adult info below
Total #Tags (if allowed)
______ X cost $ ______ = $ _______
Please provide count only
TOTAL NUMBER ATTENDING ______
TOTAL
= $ _______
Check enclosed # _____
$ _______
Payment:
Amount
Credit Card:
Mastercard
Visa
Discover
Card Number _____________________________________ Exp. Date: ______________ 3 Digit Code _____________
Amount: $_______________ Signature: _______________________________________________________________
Please provide names and addresses for all girls and adults who are planning to attend this event.
Not all events offer a t-shirt.
Remaining boxes to be fi lled out by girls and adults
attending the event.
This box is to be fi lled out by the person who will be receiving
the confi rmation letter. If you do not list an e-mail,
confi rmation will be mailed.
Girl
Adult
Name: ______________________________________
Are you attending?
Yes
No
Address: ____________________________________
City: _________________ State: ____ Zip: ________
Phone: _____________________________________
Leader
Co- Leader
Parent/Guardian
Special needs/allergies:________________________
Name: ______________________________________
T-shirt sizes:
YS YM YL AS AM AL AXL A2XL A3XL
Address: ____________________________________
(check one)
City: _________________ State: ____ Zip: ________
Phone: _____________________________________
Special needs/allergies:________________________
Girl
Adult
T-shirt sizes:
YS YM YL AS AM AL AXL A2XL A3XL
Name: ______________________________________
Address: ____________________________________
City: _________________ State: ____ Zip: ________
Email: _____________________________________
Phone: _____________________________________
.
Please note: Confi rmations will be sent via e-mail, if e-mail is listed
Special needs/allergies:________________________
T-shirt sizes:
YS YM YL AS AM AL AXL A2XL A3XL
(check one)
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