Day Camp Individual Registration Form - 2016
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1
22016 Day camp individual
registration form
Name of parent/guardian __________________________________________________________________________________
Home phone _______________________ Work phone ______________________ Cell phone ________________________
Email address _________________________________ Address ___________________________________________________
City ___________________________________________ State _______ County _________________ ZIP ________________
Emergency contact:
Name __________________________________________________________ Relationship ____________________________
Primary phone ___________________________________Secondary phone ______________________________________
My daughter is under the custodial care of:
Other ______________________________________________
q
Both parents
q
Mother only
q
Father only
q
Camper’s name ____________________________________________________________ Birth date ____________________
School ___________________________________ Grade in fall __________ Shirt size (specify youth or adult size) _______
Parent permission:
I give my daughter, ________________________________, permission to participate in all phases
of the Girl Scouts of Central Indiana day camp program. I understand the arrangements as stated in the camp
information. I will not allow her to attend camp if she has been exposed to any contagious disease, and will notify
the camp director if this is the case. In an emergency, when neither I nor the emergency contact person named can
be reached, I hereby authorize the camp director to take any action deemed necessary for the best interests of my
daughter. I understand that part of the learning experience of day camp is living with peers; therefore, there is no
visitation during sessions. I give permission for out of day camp travel when it is part of the day camp program. I give
permission for all photos and videos of my daughter at day camp to be used for public relations purposes for Girl
Scouts of Central Indiana.
Signature of parent/guardian___________________________________________________ Date _____________________
Are you currently a registered member of
q
Hispanic or Latina
q
Not Hispanic or Latina
Girl Scouts of Central Indiana?
Fee waiver information
Yes, troop # __________ Service unit _____________
q
Name of adult volunteering to work at day camp who is
q
Yes, Juliette (individual Girl Scout)
responsible for waiver of fee
q
No, non-Girl Scout (Fill out a membership
__________________________________________________
registrtation form on page 64.)
Program Assistance Grant (PAG) Information
q
Out of council
q
q
Is financial assistance needed?
Yes
No
Council name ___________________________________
If yes, include PAG application and $10 deposit.
Additional information
Disabilities
(optional for statistical purposes only)
q
Please check if you need American Disabilities Act
Camper’s racial background
assistance. Explain ________________________________
__________________________________________________
q
American Indian or Alaskan Native
q
Black or African American
Buddy information (campers only)
q
Hawaiian or Pacific Islander
Name one friend (first and last name ) that you want in
your unit.
q
White
__________________________________________________
Other (Specify ______________________________ )
q
Grade in fall (must be same as camper’s) ____________
Camper’s ethnic background
49
2016
CAMP GUIDE
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