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Participant Registration: (please complete a separate form for each girl)
Girl’s Name: _______________________________________________________________________ Mailing Address:____________________________________________________________________ Parent/Guardian Name: ______________________________________________________________ Date of Birth: ____________________________________ Grade: ___________________________ Phone: __________________________ Email: ___________________________________________ Girl Scout Troop # (if member) _______________ Check here if not a member _____
Person to contact in case of emergency (other than parent) Name:________________________________________________ Phone #_____________________ Relationship: ______________________________________________________________________
Please list any medical, emotional or physical concerns the staff needs to be aware of, including medications, allergies and medical conditions: __________________________________________________________________________________ __________________________________________________________________________________
Permission is given for my daughter to participate in this event. Permission is also granted for my daughter to receive emergency treatment and/or anesthesia from qualified personnel if necessary. I understand that when participating in Girl Scout activities, my daughter may be photographed for print, video or electronic imaging. I understand that the images may be used in promotional materials, news releases and other published formats for Girl Scouts. I acknowledge that the images will be the sole property of Girl Scouts.
Signature of Parent/Guardian:__________________________________________________________
Date:_______________________________
Participation Fee: $5.00 per person
Please make checks payable to: GSSWC Chester
Please return this form with payment to Nancy Pilotte, 153 Meadow Fox Lane, Chester, NH 03036 no later than OCTOBER 3, 2008
NO ADMISSIONS AT THE DOOR, YOU MUST PRE-REGISTER.
If you have any questions, please call Nancy at 887-3642
Chester Girl Scouts
Additional forms available on our web site |
