Program Event Registration Form

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Program Event Registration
Please check one: q Attending as individual q Attending as Troop
OFFICE USE ONLY
q Troop # ________________________________ Service Unit # _____________________________________
Date Received: ________________________________
Grade Level(s): q Daisy q Brownie q Junior q Cadette q Senior q Ambassador
Cash ______ Check ______ Debit/Credit Card ______
Receipt #: _____________________________________
Primary Adult Contact Name___________________________________________________________________
Amount Received: ______________________________
E-mail Address _______________________________________________________________________________
Date Confirmation Sent: _________________________
Mailing Address ______________________________________________________________________________
Please return this form and payment to any Girl Scout
Service Center by registration deadline.
City _________________________________________________________________________________________
Please return them as soon as possible as events
may fill before the registration deadline.
State _________ Zip __________________ Phone Day ______________________________________________
Columbia Service Center
130 Pinnacle Point Ct., Suite 100 | Columbia, SC 29223
Evening ____________________________________ Cell _____________________________________________
T 803.782.5133 | F 803.782.0410
Greenville Service Center
Event/Workshop Name _______________________________________________________________________
Five Independence Pointe, Suite 120 | Greenville, SC
29615 | T 864.770.1400 | F 864.272.3394
Date of Event/Workshop ________________________________ Session _____________________________
Spartanburg Service Center
349 East Blackstock Rd. | Spartanburg, SC 29301 T
Attach all Cookie Dough to registration form.
864.576.2514 | F 864.587.7367
Sister-to-sister transfers will be accepted for sisters living in the same household.
Amount Due
Amount
Amount being used
Name(s) of Girl(s) Attending
Grade
being paid
from Cookie Dough
Put a star next to the names of any non-Girl Scouts
_____ girls x
$_______ fee
=
$ _________
_____ girls x
$_______ fee
=
$ _________
_____ adults x $_______ fee
=
$ _________
_____ adults @ no fee
=
$ _________
Donation to Help Others
=
$ _________
Total Due
$ _________
Minus Total Cookie Dough
$ _________
Amount Enclosed
$ _________
Name(s) of Adult(s) Attending
Yes, I am willing to have a
I am interested in having
Please indicate if any of the girl participants or adult volunteers
short volunteer assignment
a volunteer assignment
will need special accommodations:
during the event.
during the entire event. No
charge. Please provide your
q Wheelchair accessibility
phone # below.
q Physical assistance
q Dietary Restrictions (describe):
________________________________________________________
Other (describe):
________________________________________________________
________________________________________________________
Photos / videos / recordings of all registrants may be used by Girl Scouts q Yes q No
List any exceptions _____________________________________________________________________________________________________________________
Make checks payable to: GSSC-MM
If paying by credit/debit card please include the following information:
CC# may be called in to the Service Center receptionist.
q Visa q Mastercard
Credit/Debit Card Account # _______________________________________________ Expiration Date _______________ 3-Digit Code ___________________
Name as it appears on the card ________________________________________ Cardholder Signature ______________________________________________
Cardholder’s Complete Mailing Address ___________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
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