GIRL SCOUTS OF CONNECTICUT
20 Washington Avenue, North Haven, CT 06473
1-800-922-2770
A
P
-
A
F
NNUAL
ICK
UP
UTHORIZATION
ORM
(
(
)/L
G
(
))
TO BE COMPLETED BY PARENT
S
EGAL
UARDIAN
S
•
Please complete this form for anyone, including parent(s)/legal guardian(s), who will pick up your Girl Scout from Troop/Group meetings/events,
regardless of where the meeting/event takes place. Please write clearly.
•
Submit this completed form (one per Girl Scout) to your Troop/Group Leader prior to the girl’s first Troop/Group meeting/event of the current
membership year.
•
Girl Scouts of Connecticut gives high priority to ensuring the safety of girls attending Girl Scout meetings/events; therefore, we will not release
girls to anyone except a parent or guardian without a completed form.
•
Please inform each of the persons listed below that they must be prepared to show identification when picking your girl(s) up.
Please Note: Any changes to the information provided below must be given to the Troop/Group Leader in writing.
Girl Information
Name of Girl Scout (first, middle, last)
Troop/Group #
Level:
D
B
J
C
S
A
Parent/Guardian Name
Home Phone
Cell Phone
Email
Parent/Guardian Name
Home Phone
Cell Phone
Email
The following person(s) are authorized to pick up my Girl Scout from Troop/Group meetings or events
Primary pick-up person(s)
Name
Address
Relationship
Phone
Name
Address
Relationship
Phone
Additional persons who may pick up my Girl Scout (
a photo ID must be furnished)
Name
Address
Relationship
Phone
Name
Address
Relationship
Phone
Name
Address
Relationship
Phone
Name
Address
Relationship
Phone
Name
Address
Relationship
Phone
Permission to Walk Home from Girl Scout Meetings/Events
My Girl Scout has my permission to walk home from Girl Scout meetings/events.
Yes
No
I verify that all the above information is true and correct to the best of my knowledge.
Parent/Guardian Signature*
Date
*Original Signature Required
Annual Pick-up Authorization Form - 9-14-12
(Reviewed 10-24-14)