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