Summer Camp Registration Form - Girl Scouts Of The Missouri Heartland Page 2
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2Parent/Guardian Permission
I, the undersigned parent/legal guardian of _____________________________ (“child”), authorize the child’s participation in Girl Scout
Summer Camp (“the program”) and all related activities, including horseback riding, archery, ropes, and water sports. I have read the camp
information and I understand it and agree to cooperate with all the regulations. The camp staff has permission to seek medical attention for the
child in the event of an accident or sickness, to administer any prescription drug sent to camp with the child or any medication prescribed in
the event of an accident or illness, and to administer any non-allergic over-the-counter medicines as needed (such as Tylenol). I give
permission for out-of-camp travel which is part of the program. Girl Scouts of the Missouri Heartland has permission to use pictures, slides,
and/or audio-video tapes of the child taken while she is involved in activities for council publicity and public relations purposes. I feel the child
is prepared for camp, and understand that, if possible, homesick children will not be sent home, but will be closely observed and helped to
overcome the separation anxiety they are experiencing.
I recognize and acknowledge that there are certain risks of physical injury to the child in the program. I, the child, and my insurer,
hereby release, waive, relinquish, and discharge Girl Scouts of the Missouri Heartland, Inc. and any and all directors, officers,
employees, agents, and/or volunteers from any and all claims, demands, action, or causes of action whatsoever, arising out of or
related to any loss, damage, or injury, including death, that may be sustained by the child as a result of the child’s participation in
the program, whether caused by negligence (including, but not limited to, negligence by any person acting on behalf of the Girl
Scouts of the Missouri Heartland, Inc., negligent training, or negligent supervision) or otherwise. I further acknowledge that I
understand that this is a full release and that I have voluntarily waived my rights and those of the child and insurer.
Parent/Guardian Name ______________________ Signature ________________________ Date ____________
Payments
A minimum $40 deposit is required for a camper to be registered in a session.
Use the following camp fee calculator to determine your total fee and balance due.
Summer Camp Program Session Fees
a. $
st
a. Resident Camp Program Session Fee for 1
Choice Session
b. Membership Registration Fee
b. $
2015-2016)
($15, if not already a registered Girl Scout for 2014-2015)
c. $
c. Camp T-shirt
(please circle size)
Sizes & Pricing: YS YM YL AS AM AL AXL A2XL A3XL A4XL A5XL: $10
Size:
0
d. Add (a), (b), and (c) for subtotal
d. $
Payments Enclosed
40
$ 40
Deposit required: $40 is required and applied towards fees
Additional Payment: Make an additional payment towards total fee (line d)
$
40
Total Enclosed [should not exceed the amount listed on line (d)]:
$
Payment Methods
$
Cash* or Check (payable to Girl Scouts of the Missouri Heartland)
(*Do not mail cash)
Cookie Credit
(if applicable) (Make sure to include 2-digit security code located on back of card)
$
Cookie Credit Gift Card #:__ __ __ __ __ __ __ __ __ __ __ __-__ __ __ __ __-__ __
Credit Card (Please complete information below)
$
Credit Card Type:____________ Card #____________________________ Expiration Date:__________
Name on Card:____________________________ Signature:__________________________________
0
Total Payment (should match total enclosed)
$
Any applicable fees must be received by 2 weeks prior to your camp session. Forms may be faxed, emailed, mailed, or
hand-delivered to any Girl Scout service center. For service center mailing addresses and hours, please visit our website.
Faxed and emailed forms must include a credit card number for payment.
●
●
●
For Office Use Only
Budget # __________ Check # __________ Date __________ Total Enclosed __________ Staff Initials _______
P:\Forms\Public\External\Resident Camp\Summer Camp Registration 340115
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