Western Communities Event
Registration Form
Today’s Date: ____________ Registration Deadline: ____________
Event / Activity Name: ______________________________________
Event Date: ______________ Event Time: ____________________
Event Location: ___________________________________________
Troop/Group No: _____ Service Unit: ____ Program Level: ________
Adult Volunteer / Advisor Name (or participant if individual girl): _____________________
Email Address (important for confirmation): _________________________
Address: ______________________ City: ______________________
Zip Code: _________________
Phone No: Day: _____________ Eve: __________________________
For Individually Registering Girls: (we can pair your daughter with a troop)
I, (parent) _________________________ give my permission for the child to attend the above stated event / activity.
My child _______________________ is in good health and is able to participate in the activity.
_____I plan on staying at the event and will participate with my child.
_____My child will be participating in this event with
Girl Scout Troop_____ and Adult Volunteer/Leader/Advisor: ______________
This leader's phone number is: _________________________
If parent does not attend:
Person to contact in case of emergency: __________________
Phone Number: _____________________________________
Form of Transportation (i.e. van, cars, train, etc) ___________________________________
Adult Volunteer/Advisor’s electronic Signature: __________________________________ Date _________________
Roster of all participants including girls, adults, and tag-a-longs. Participants not registered with GSUSA may require additional Girl Scout insurance coverage. (Please consult event chair for further information on who can attend.)
Roster of Girls Attending:
Additional Adults Participating:
________________________________ Phone ________________ Email _______________
________________________________ Phone ________________ Email _______________
First Aider, (if applicable)____________________ Certification Expires_______
At Home Contact ___________________________ Phone ______________ Email ______________
Troop Camper (if applicable) __________________ Phone ______________ Email ________
Lifeguard (if applicable) _____________________ Phone ______________ Email ________
Name of Course Completed ____________________ Certification Expires_______
Water Watcher (if applicable) _________________ Phone ______________ Email ________
Tent Pitcher (if applicable)____________________ Phone ______________ Email ________
* Fees:
Fee for participants: $________ x number of participants _______ = $_________ Total due
Payment Method: _______ Check (Girl Scout Troop 411) ________ cash
**Sorry no refunds unless event is canceled.
Mail form with payment to (unless otherwise stated):
Carolyn “Ocean” Friedman
110 Galiano Street
Royal Palm Beach, FL 33411
Phone: 561-310-6514
Email: cfocean32@yahoo.com
*Note: This form can be filled out and sent via email to Ocean and /or the event chair to reserve your troops' registration. If the event is a FREE event no further action is needed. Upon receipt of your registration, you will receive an email confirmation.
If there are fees associated with the event, you must mail a check to Ocean Friedman and / or the event chair by the registration deadline or your troops' registration cannot be guaranteed. If the event has limited space and payment is not made by the registration deadline and other arrangements have not been made, troops on a "waiting list" will be used to fill the event.
*Hurricane Policy: When the National Weather Service issues a Hurricane Watch or Warning for any portion of the council jurisdiction, during the time period for which a Girl Scout activity is scheduled, the event will automatically be postponed. After the weather emergency has passed, you will be contacted regarding the reschedule or cancellation.
Confirmation Notice:
Date: _________________ Event Chair: ________________________
You Are Confirmed for this event: ______
Sorry, the event is full, if there are any cancellations, we will be in touch: ____
Travel Application Approval Information: Council Use Only
Your request for approval of (activity) __________________ is: o approved o not approved (see reverse for reasons.)
Approved By: ____________________________________ _______________________
Volunteer Program Manager Date
____________________________________ _______________________
Membership Manager Date
Based on the information provided:
o Application complete—Have a great time!
o First Aid / CPR Required
o A record of health examination (physical checkup) may be required for each participant. See Safety Wise
Standard 3.
o Helmets required for activity.
o Adult in charge must verify that the activity provider has shown evidence of current liability.
o Other ____________________________________________________
Girl Scouts of the Western Communities 8/2008