2009 Event Registration Form

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This is the 2009 event registration form. You can use this for the NASA rocket event in September.

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2009 Event Registration Form

  1. 1. Girl Scouts of Louisiana - Pines to the Gulf Program/Event Registration Form Please Print & Include Registration Fee Return to any service center to the ATTN: Program Department. Registration is for: Troop/Group Adult * Non-registered Girl Scout * Individual Girl - not registering with a troop (*complete individual girl information below) Event Code (mandatory):__________ Event Name______________________________________________ Event Date_______________ Program Age Level (please check): Daisy Brownie Junior Cadette Senior Ambassador Juliette Service Unit #_______________ Troop #_________________ Parish______________________________________________________ ___________________________________________________________ Email_______________________________________________ Troop Leader’s Name (please print clearly) Address_________________________________________________ City___________________________________ Zip_____________ Phone # (H) (______) __________________ (W) (_______) _______________________ (C) (_______) ____________________________ Cost per girl $______ Cost per adult $_______ AI/AN A B/AA H/PI H/O W TOTAL Total Amount Enclosed $_________________ # Girls Payment in FULL is required for form to be processed. Send payment amount for only event listed on form # Adults Payment Information (please check): Check (Payable to Girl Scouts of Louisiana - Pines to the Gulf) Key: AI/AN – American Indian/Alaskan Native A – Asian MC VISA Discover Cookie Dough B/AA - Black or African American H/PI – Hawaiian/Pacific Islander Name on Card_________________________________________ H/O – Hispanic, Other W - White Account # _____/ ______/_______/________ Exp. Date_____/____ Cardholder Signature________________________________________________ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- THE FOLLOWING MUST BE COMPLETED AND SIGNED BY A PARENT/GUARDIAN FOR ANY GIRL REQUESTING TO ATTEND AN EVENT OR ACTIVITY AS AN INDIVIDUAL. ***For girls attending with a troop/group – troop adults are responsible for obtaining parent permission and health information for participating members unless requested otherwise in the event details. Please list full names of girls and adults attending the event on the back of this form. List any health conditions that event coordinator should be aware of or would limit girl’s participation in activities: __________________________________________________________________________________________________________________ List current medications:______________________________________________________________________________________________ Allergies to medication, food, insects, etc.________________________________________________________________________________ Physician or Clinic:______________________________________________________Phone (_____)________________________________ Person to notify in case of emergency, if parents cannot be reached: Name_________________________________________________________________Phone (_____)________________________________ Address_____________________________________________City____________________________State____________Zip____________ I give permission for my daughter to participate in the activity listed at the top of this event form, including transportation, if provided, to and from the program sites. I hereby give Girl Scouts of Louisiana – Pines to the Gulf the right and permission, without compensation to use photographs/videos of my daughter and her name for publicity and public relations purposes. I give permission for my daughter,________________________,to receive emergency medical treatment if necessary. __________________________________________________ _________________________________________ Signature of Parent/Guardian Date

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