Form 215 Pm - Event Registration Form
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1501 S. College Ave.
Event Registration
Newark, Delaware 19713-1301
T 302-456-7150 • 800-341-4007
Please print clearly or type, then mail, fax or email to
F 302-456-7188
GSCB at
OR call: (302) 456-7182
*Event Registrations will not be processed until payment is received.
Girl Adult Ratio for Events
Registration deadline is 14 days prior to event. The following late fees will incur per participant:
Two adults for every:
$0 - $10 = $1 per participant
$11 - $20 = $2 per participant
6 Girl Scout Daisies. For each 4 additional Daisies, one additional adult is required.
$21 - $40 = $4 per participant
$41 & over = $6 per participant
12 Girl Scout Brownies. For each 6 additional Brownies, one additional adult is required.
Event date: _____________________ Time: ________ Location: __________________________
16 Girl Scout Juniors. For each 8 additional Juniors, one additional adult is required.
Event name: ______________________________________________________________________
20 Girl Scout Cadettes. For each 10 additional Cadettes, one additional adult is required.
First name: _____________________________ Last name: _______________________________
24 Girl Scout Seniors. For each 12 additional Seniors, one additional adult is required.
Troop #
Service Unit:
Email: ___________________________________________
24 Girl Scout Ambassadors. For each 12 additional Ambassadors, one additional adult is required.
Address: _________________________________________________________________________
Girls Attending
City: ___________________________________________ State: ______ Zip: _________________
Name: ___________________________________________ Grade:
Day phone: _____________________________ Cell phone: ______________________________
Name: ___________________________________________ Grade:
# Girls: _______________ x fee: $ ____ = Total due: $ ______ Amount enclosed: $ __________
Name: ___________________________________________ Grade:
# Adults: _____________ x fee: $ ____ = Total due: $ ______ Amount enclosed: $ __________
Name: ___________________________________________ Grade:
# Non-members: ________ x fee: $ ____ = Total due: $ ______ Amount enclosed: $ __________
Name: ___________________________________________ Grade:
Grand total due $ _________ Total enclosed $ ___________
Name: ___________________________________________ Grade:
Indicate payment type: Check Visa
Master Card
Discover
Name: ___________________________________________ Grade:
Check details:
Name: ___________________________________________ Grade:
Name on check: ________________________ Check #: ______ Mailed: _________________
Name: ___________________________________________ Grade:
Driver’s License #: _______________________________________________________________
Name: ___________________________________________ Grade:
Credit card information:
Name: ___________________________________________ Grade:
Name on card: __________________________________________________________________
Name: ___________________________________________ Grade:
Card # : _______________________________________________ Exp. Date: _______________
Name: ___________________________________________ Grade:
Billing Zip:
Name: ___________________________________________ Grade:
CSV (security code):
Name: ___________________________________________ Grade:
Does anyone in your troop have any special needs such as cognitive, physical, dietary, allergy, etc.?
Adults Attending
Please explain (include girl’s name): _________________________________________________
Name: ____________________________________
Phone: ______________________________
______________________________________________________________________________
Name: ____________________________________
Phone: ______________________________
______________________________________________________________________________
215 PM 6/15
215 PM Event Registration Form
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