Fillable Registration Form printable pdf download

REGISTRATION FORM

Use this form to register for Council-Sponsored Program Events, Training Sessions and Summer Camp sessions. Complete a separate form

for each event, and provide all the information requested. Duplicate this form as needed. Fax registration with credit card information to

651-227-7533, or mail with payment to: 400 Robert Street South, St. Paul, MN 55107. You may also register on the website at .

Registering as:

Individual Adult

Troop

Add-on participants to Troop

Individual Girl with Adult Participant

Individual Girl without Adult Participant

Name: _______________________________________________________________________________ Date: ___________________________________

(Person filling out form-main contact: include last name, first and middle initial)

Address: _____________________________________________________________________________ Day Phone: ______________________________

City/State/Zip: ________________________________________________________________________ Evening Phone: __________________________

E-mail Address: _______________________________________________________________________ Cell Phone: ______________________________

Girl name: ____________________________________________________________________________ Grade and birthdate: _____________________

(When registering as an Individual Girl with or without Adult Participant: include last name, first and middle initial)

Service Unit (if known): _________________________________________________________________ Troop #: _________________________________

Registering For:

Event/Session Title: ____________________________________________________________________ Start Date: _______________________________

Event/Session Location: _______________________________________________________________ End Date: _______________________________

Time - Only include for one day event/session - (Begin - End): ______________________________

List any accommodations needed: (accessibility, dietary, interpreter, allergies, etc.): _____________________________________________________

_________________________________________________________________________________________________________________________________

Payment Information: Please include full payment for all participants listed on this form.

Fee per girl:

________________ x ____________

# of girls =

$ ___________

Fee per adult: ________________ x ____________

# of adults =

$ ___________

Girl Scout membership fee (if not registered member of River Valleys’ include a $15 non-refundable fee)

Number of new members:__________________

$15 =

$ ___________

I’d like to make a tax-deductable gift to send other girls to

•

Please note that full payment must be included for

support scholarships for girls to attend Girl Scout programs:

$ ___________

Council-Sponsored Program Events, Training Sessions,

Total Enclosed:

$ __________

and Summer Troop, Family and Adult & Me sessions.

Method of Payment:

•

Those registering for summer resident camp sessions

Check or money order payable to River Valleys:

$ ___________

for individual girl without adult participants, either full

Cookie credits enclosed (for girl fees):

$ ___________

payment or $50 non-refundable deposit must be included

Fall FUNds enclosed (for girl fees):

$ ___________

with registration or it will be returned as incomplete.

If applying for a summer camp grant must include a

Camp voucher enclosed (for summer camp):

$ ___________

minimum of $10 non-refundable deposit.

Gift Certificate enclosed:

$ ___________

Girls/Adults Grant application(s) request:

$ ___________

•

Those applying for a grant must send in a completed

Charge my credit card:

$ ___________

grant form with the registration form

Credit Card Type:

Visa

Master Card

Discover

Credit Card Number: _________________________________________________ Expiration Date:____________ 3-digit Security Code: ____________

Cardholder’s Name: ___________________________________________________________________

Cardholder’s Signature: ________________________________________________________________

If you are registering for a Council-sponsored Program Event or Summer Camp session, please fill out information on next page.

Registration Form

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