Girl Scouts Of The Missouri Heartland Event Registration Form
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2Girl Scouts of the Missouri Heartland, Inc.
Event Registration Form
*Please complete all fields in their entirety; incomplete forms cannot be processed.
Event Information
Event Name ___________________________________________ Option (if applicable) ___________
Date _____________ Time ____________ Location ________________________________________
Registration Information
5-Digit Troop/Group # ___________ Service Unit Number _________ County ____________________
Age Level
Daisy
Brownie
Junior
Cadette
Senior
Ambassador
(K-1st)
(2nd-3rd)
(4th-5th)
(6th-8th)
(9th-10th)
(11th-12th)
Attending Adult Name (if required) ______________________________________________________
If adult attendance is required to meet girl-adult safety ratios, then the adult(s) with the group will be responsible for bringing a
signed parent permission and health history form for each girl attending, as per Girl Scout safety standards, and for keeping
the forms with them during the program.
Address ___________________________________ City ______________State _____ Zip ________
Phone _____________________ E-Mail _________________________________________________
(Confirmations sent via email unless otherwise requested. Do not attend the program if you have not received a confirmation.)
Parent/Guardian Name (if different than above) ____________________________________________
If girl is attending event individually, parent/guardian should send signed parent permission form and health history form to the
event. Forms are available at
E-Mail Address _____________________________________________________________________
(Confirmations sent via email unless otherwise requested. Do not attend the program if you have not received a confirmation. )
Program Fees (Check program description for pricing.)
# of girls attending:
_____
x cost per girl:
$ ______ =
Total girl fees:
$ _______
# of adults attending:
_____
x cost per adult:
$ ______ =
Total adult fees:
$ _______
# of girl/adult Girl Scout membership registrations: ______ x $12 =
Total fees:
$_______
TOTAL GIRL AND ADULT FEES
$_______
Payment Methods
Check(s), made payable to Girl Scouts of the Missouri Heartland, Inc.
$________
Cookie Credit (if applicable)
(Make sure to include 2-digit security code located on back of card).
Cookie Credit Gift Card # _____________________________ - ____________ - __ __
$________
500+ Box Seller Program Credit (if applicable)
Girl’s Name _______________________________ 5-Digit Code (
__________
$________
from Program Voucher)
Financial Assistance Application for Program Activities
(Financial assistance form must be attached for each person requesting it.)
$________
Credit Card
$________
(Please complete information below.)
TOTAL ENCLOSED
$________
Credit Card Type: ___________
Card #: ______________________________ Expiration Date:________
Name on Card: _______________________ Signature: ________________________________
Trainings (Please check any that apply.)
CPR/First Aid Certified Name: __________________________ Phone: (____)___________
BOS Trained
Name: __________________________ Phone: (____)___________
I am available to assist with program as: F irst Aider
C heck-in Desk
(Page 1 of 2)
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