Annual Consent Form - Girl Scouts Of Connecticut
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1GIRL SCOUTS OF CONNECTICUT
1-800-922-2770
A
C
F
NNUAL
ONSENT
ORM
Please keep this form with your Troop/Group records.
SERVICE CENTERS
Hartford
340 Washington St.
Hartford, CT 06106
Girl Scout's Name (Please print)
Phone
(860) 522-0163
Fax (860) 548-0325
Address
City
ST
Zip
Lebanon
175 C Clubhouse Rd.
Parent/Guardian Permission for medical treatment, transportation, publicity,
Lebanon, CT 06249
troop/group meetings, money-earning activities, and product sale activities.
(860) 423-5502
Fax (860) 423-7953
Initial if you agree with the following:
North Haven
_____ I give permission for my Girl Scout (daughter/ward) to participate in regular
20 Washington Ave.
Girl Scout activities, including troop/group meetings, and money-earning
North Haven, CT 06473
activities.
(203) 239-2922
Fax (203) 239-7220
_____ I give consent for my Girl Scout to be interviewed, photographed, videotaped,
or electronically imaged for the purposes of promotional materials, news
Waterbury
releases, or other published formats** for either the local Girl Scout Council
171 Grandview Ave.
or Girl Scouts of the USA. The images will be the sole property of the local Girl
Suite 102
Scout Council or Girl Scouts of the USA. I hereby release and hold harmless
Waterbury, CT 06708
the local Girl Scout Council and Girl Scouts of the USA from any claim arising
(203) 757-1340
from the use of these images.
Fax (203) 591-1729
_____ In case of an emergency, I hereby authorize Girl Scout adults and/or a
Wilton
currently certified First aider to give necessary first aid/CPR to my Girl Scout.
529 Danbury Rd.
I also authorize the person in charge to obtain and consent to, on my behalf,
Wilton, CT 06897
whatever medical diagnosis treatment is deemed necessary or advisable by
(203) 762-5557
such person for the well-being of my Girl Scout.
Fax (203) 762-0688
_____ Troop/Group adults have my permission to transport my Girl Scout on a
troop/group trip or in case of an emergency.
_____ My Girl Scout may participate in product sale activities (QSP and cookies) and
use appropriate on-line resources. I agree to accept responsibility for all
products and money she receives and will see that she has adult supervision
at all times while doing product sale activities. I understand that no incentives
will be given unless all money is turned in to the Troop/Group Product Sales
Manager or designee by the due date.
_________________________________
_________________________ ________
* Parent/Guardian Signature
Parent/Guardian Name (Please print)
Date
2
nd
year ________________________
________
* Parent/Guardian Signature
Date
* Original Signature is required.
**The term “published formats” incorporates the council website , but
images used on the website and elsewhere, with the possible exception of the council
newsletter, will NOT reveal a person’s full name and town. Girl Scout websites are required
to comply with council website and print safety restrictions. Girl Scout members should
not send to local or council publicity contacts photos of any girl whose parent/guardian
has not completed an Annual Consent Form.
Annual Consent 9-8-15
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