Leader/Adult/Participant Name___________________Daytime Phone ______________
Street Address_______________________________Evening Phone _______________
City _______________________________________Zip Code __________________
Service Unit # _______Troop/Group #________Program Age Level: . D . Br . Jr . Cd . Sr

Course/Program . . . . . . . Name of Adult for Training . . . . . . Girl Fee . . . . . # of Girls . . . . . . .Fee . . . . . . . . . . . . . . . . . . TOTAL
Workshop Name . . . . . . Or Date(s)of Camping Or . . . . Fee per Participant . . . OR . . . . . Adult/Tagalong . . .# of Adults/
Facility Name . . CODE . . Date & Time of Workshop . . . Facility Use Fee . . . # of Days . . . . . (if applicable) . . . Tagalongs

1st. . . . . . . . . . .| . . . . . .| . . . . . . . . . . . . . . . . . . .| . . . . . . . . . . . . . . . | . . . . . . . . . . | . . . . . . . . . . . . . .| . . . . . . . . . . | . . . . . . .

2nd . . . . . . . . . .| . . . . . .| . . . . . . . . . . . . . . . . . . .| . . . . . . . . . . . . . . . | . . . . . . . . . . | . . . . . . . . . . . . . .| . . . . . . . . . . | . . . . . . .

3rd . . . . . . . . . .| . . . . . .| . . . . . . . . . . . . . . . . . . .| . . . . . . . . . . . . . . . | . . . . . . . . . . | . . . . . . . . . . . . . .| . . . . . . . . . . | . . . . . . .

1st . . . . . . . . . . .| . . . . . .| . . . . . . . . . . . . . . . . . . .| . . . . . . . . . . . . . . . | . . . . . . . . . . | . . . . . . . . . . . . . .| . . . . . . . . . . | . . . . . . .

2nd . . . . . . . . . .| . . . . . .| . . . . . . . . . . . . . . . . . . .| . . . . . . . . . . . . . . . | . . . . . . . . . . | . . . . . . . . . . . . . .| . . . . . . . . . . | . . . . . . .

3rd . . . . . . . . . .| . . . . . .| . . . . . . . . . . . . . . . . . . .| . . . . . . . . . . . . . . . | . . . . . . . . . . | . . . . . . . . . . . . . .| . . . . . . . . . . | . . . . . . .

-> (*)Troop/Group Camping Reservation only: Name of First Aider ___________ Daytime Phone #________
Expriation of Certification: First Aid_______CPR_______(*)Signature of S.U. Manager________________
Name of Qualified Trained Camping Adult________________Daytime Phone__________
Camp Training Segments Completed: Segment I date:_____ Segment II date:_____ Segment III date:_____
Number of girls participating ____________ Number of adults participating ____________

->Type of Payment: __CASH __CHECK#__________ Personal or Troop (please circle) NOTE: Troop checks require 2 signatures.

__Credit Card . . . . __Visa . . . . __Mastercard . . . . __American Express . . . . __Discover . . . . . . . Card#_____________________

. . . . . . . . . . . . . . . . . . . . Expiration Date______________ Cardholder Signature_______________________________

Submit reservation forn to Girl Scouts - Illinois Crossroads Council in one of the following ways:
1: Mail or walk-in completed . . . . . . . . . . . . . . . . . . . . . . . . . Girl Scouts-Illinois Crossroads Council
reservation form and payment to: . . . . . . . . . . . . . . . . . . . . . . 650 N.Lakeview Parkway
(Will NOT be accepted without payment) . . . . . . . . . . . . . . . Vernon Hills, IL 60061-1828

Fax the completed reservation form & credit card payment to: (847) 573-0400 . . . . . . . Date received:_______
(Fax accepted only with credit card payment) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amt of payment received:_______
(*)Must be completed & signed prior to placement & confirmation. . . . . . . . . . . . Confirmation Mailed:_______

Home: http://www.oocities.org/su611/

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