Troop # ___78_____ is planning a (circle one) camping, trip, or outing to _ Children’s Museum Open House located at Karpeles Manuscript Library Museum 101 W 1^st St., Jacksonville

On _Sunday, 12/2/01 _ Phone number at destination __Nadine’s Cell Phone 631-6388

ARRANGEMENTS FOR TRANSPORTATION: Carpool

Time and place of departure: 12:30 PM at St. Luke’s Episcopal Church Main Parking Lot

Time and place of return: 3:30 PM at St. Luke’s Episcopal Church Main Parking Lot

Leaders accompanying the girls: Nadine Cayasso, Wanda Stephens, Kelley McNamee

Each girl will need: Sneakers and Troop Tee shirt

________________________________________________________________________________________________

The emergency contact is: Nadine Cayasso (cell phone) 745-8610

Nadine Cayasso / Wanda Stephens/Kelley McNamee 745-8610 / 220-1988/721-7532

Troop Leader Home Phone number

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

My daughter, ______________________________________________ troop # 78 has permission to participate in Children’s Museum Open House 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