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