Troop # ________ is planning a (circle one) camping, trip, or outing to ________________________________

On ____/____/____ Phone number at destination _______________________________________________

ARRANGEMENTS FOR TRANSPORTATION:

Time and place of departure:

Time and place of return:

Mode of transportation:

Leaders accompanying the girls:

Each girl will need:

________________________________________________________________________________________________

The emergency contact is

________________________________________________________________________________

Troop Leader Phone number

(Cut and return bottom portion of Troop Leader/Assistant Leader by ___________________)

My daughter, ______________________________________________ troop # 78 has permission to participate in _____________________________________. She is in good physical condition and has not had any serious

illness or operation since her last health examination.

During the activity, I may be reached at:

Address ___________________________________________ City _________________ State ______ Zip __________

Day Phone ____________________ Evening Phone _______________________ Cell Phone _____________________

If other than parent or guardian, person authorized to pick up my daughter after the event:

________________________________________________________________________________________________

In the event of an emergency, if I cannot be reached the following person I authorized to act in my behalf:

Name: ___________________________________________ Relationship to participant: _______________________

Address ___________________________________________ City _________________ State ______ Zip __________

Day Phone ____________________ Evening Phone _______________________ Cell Phone _____________________

I consent to allow all pictures taken of my child to be used for publicity purposes by the Girl Scouts of Gateway Council, Inc. I hereby indemnify and hold the above organization; it’s directors, officers, and staff, harmless against any and all claims of damages arising out of the taking or use of any pictures or names of myself or my minor child or children.

____________________________________________

Parent/Legal Guardian Signature Date