GIRLAPALOOZA. Tickets on sale Feb. 15

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1 April 27 GIRLAPALOOZA Join us for a Girl Scout day at Schlitterbahn South Padre Island. Tickets are $35 each and include the Girl Scout registration for Sibling tickets are also available. Tickets on sale Feb. 15 Ticket purchases are contingent upon registration or re-registration of a Girl Scout. All forms will be located at on Feb. 15. Registration forms and tickets may be purchased at all five service centers or can be mailed to: Belinda Jenkins, 1109 W. Nolana, Suite 202, McAllen, Texas, For questions, call Belinda at (956) Tickets will not be sold without Girl Scout registration forms. Sibling tickets are also $35 and include a meal.

2 Girlapalooza Info Tickets on sale Feb. 15 Tickets for Girl Scouts and their parents are $35 per person and include admission into the indoor/outdoor waterpark at Schlitterbahn from 10 am to 7 pm on Saturday, April 27. Tickets also include registration or re-registration for girls and adults. Registration forms must be turned in when purchasing tickets. Tickets must be purchased in advance at all council offices. Girls who register through this event will receive the Spring Registration patch. Sibling tickets may be purchased for $35 and includes admission into the park as well as a meal band. Meals include hamburger or chicken strips with chips and a drink. Additional meal bands may be purchased for $6.50. Families may also bring their own food. See below for details on reserving a room at the new Schlitterbahn Beach Resort. There is no charge to the indoor/outdoor waterpark for children under 3 years old.

3 Room Reservations: The new Schlitterbahn Beach Resort is available from Friday, April 26, 2013 through Sunday, April 28 th at a very special rate of $89.00 per night (regular rate is $199 per night). Reservations can be made now by calling the Resort at 956/ and asking for the Girl Scout rate. The cut off date for making reservations is April 5 th and beyond that date, rooms will be on a space available basis. Please note that tickets to the Girlapalooza event or waterpark wristbands for Saturdaymust be presented at check in to the front desk to verify attendance to the Girl Scout Event and to receive the Girl Scout room rate and waive the $25. Check in is 4pm and check out is 12 noon. Rooms must be guaranteed with a major credit card. Check in Saturday, check out Sunday For guests staying at the resort who want to visit the indoor/outdoor water park on Sunday the fee is $25 per person. The regular admission at the gate is $46.99 plus tax for adults and $37.99 plus tax for children. The water park is open from 10am-6pm on Sunday. Check in Friday, check out Saturday If you check in on Friday between the hours of 4pm-8pm, you will be charged an additional water park entrance fee of $25 per person whether you visit the water parkfriday or not. If you arrive after 8pm, the fee will be waived. Check in Friday, check out Sunday If you arrive Friday between 4pm-8pm, you will be charged an additional water park entrance fee of $25 per person which will include entrance to the water park on Friday andsunday. So you will have entrance Friday evening and all day Sunday for $25. If you arrive Friday after 8pm, you won t pay the fee for Friday but if you want to visit the water park on Sunday, the fee will be $25. *Cancellations for rooms may be made up until 72 hours prior to arrival. If you fail to arrive, your credit card will be charged a one-night room and cancellation fee. If you need to depart early from your original departure date, please let the front desk know upon check in or you will be subject to a charge of one night room and tax.

4 Check one: New Member Renewing Member GSUSA ID (if known) PARENT/GUARDIAN INFORMATION DEMOGRAPHICS GIRL INFORMATION Name: First Middle Last Girl Membership Join the global network of 3.2 million Girl Scouts Membership Year through 9/30/20 Address Apartment ( ) City State / Zip Code Girl Home Phone ( ) Girl Cell Phone (only if 13 and older) Girl Address (only if 13 or older) I wish to opt in: Texts s Girl Scouts respects and welcomes people from all backgrounds and abilities. By completing the following information (as defined by the US Census), you ensure support and funding for girls in your community. Hispanic/Latina is defined as an ethnicity, not a race, therefore is reported separately. This information is used for statistical purposes only. of birth: (mm/dd/yyyy) / / # of years as a Girl Scout: School grade in Fall 2013: Name of school: Custodial care: Both Parents Mother/Guardian Only Father/Guardian Only Other Address is same as girl She is: (check all that apply) American Indian or Alaskan Native Asian Black or African American Hawaiian or Pacific Islander White Other (please specify) I choose not to share at this time She is Hispanic or Latina: Yes No I choose not to share at this time Parent/Guardian (1) First Name Middle Last Address Household income: $0 $14,999 $15,000 $34,999 $35,000 $49,999 $50,000 $74,999 $75,000 $99,999 $100,000 or more I choose not to share at this time Employer Occupation Home Phone Business Phone ( ) Cell Phone Address I wish to opt in: Texts s Address is same as girl Parent/Guardian (2) First Name Middle Last Address Employer Occupation Home Phone Business Phone ( ) Cell Phone Address I wish to opt in: Texts s GIRL SCOUT MISSION Girl Scouting builds girls of courage, confidence, and character, who make the world a better place. FUN WAYS TO PARTICIPATE: (check all that interest you) Camp: Connect with nature. Choose a camp by day or overnight. Events: Focus on half or full day events to share your passions. Series: Explore your interests over a few sessions in a way that fits your schedule. Travel: Pack your bags. Travel across town or around the world! Troop: Have fun on a regular basis with your Girl Scout sisters. Virtual: Interact virtually with Girl Scouts everywhere. YES! I would like to make a donation today that directly benefits girls in our area. Enclosed is my tax-deductible donation in the amount of: (check one) $500 $250 $150 $100 $50 $25 Other $ PAYMENT INFORMATION: Membership Fee: $ Donation: $ Total Attached: $ Cash Check* Amex Discover Visa MasterCard Other Name on Credit Card Credit Card # Expiration PERMISSION ADMIN USE Media Permission When participating in Girl Scout activities I may be photographed for print, videotaped, or electronically imaged. Images may be used in promotional materials, news releases, and other published formats for either the local Girl Scout Councils or Girl Scouts of the USA. The images will be the sole property of either the local Girl Scout Council or Girl Scouts of the USA. I wish to opt out at this time. The Girl Scout Law I will do my best to be honest and fair, friendly and helpful, considerate and caring, courageous and strong, and responsible for what I say and do, and to respect myself and others, respect authority, use resources wisely, make the world a better place, and be a sister to every Girl Scout. The Girl Scout Promise When making the GS Promise, On my honor, I will try: individual members may To serve God and my country, substitute wording appro- To help people at all times, priate to their own spiritual And to live by the Girl Scout Law. beliefs for the word God. I/We acknowledge that the registrant will accept and abide by the Girl Scout Promise and Law. The registrant has permission to join Girl Scouts. Signature of Parent/Guardian Signature of Parent/Guardian Council Code: Service Unit/Team: Group/Troop: PATHWAY OF ENTRY: Camp Event Series Travel Troop Virtual Signature *Make checks payable to Girl Scouts THANK YOU FOR SUPPORTING GIRL SCOUTS! Learn more about Girl Scouts at Return this registration form, along with GSUSA membership fees to your local council. Fees are non-refundable or transferable to another person.

5 Tipo de membresía: Nueva membresía Renovación de membresía GSUSA ID (si lo sabe) INFORMACIÓN DEL PADRE/MADRE/ TUTOR LEGAL DATOS DEMOGRÁFICOS INFORMACIÓN DE LA NIÑA PERMISO Membresía para niñas Únete a nuestra red mundial de 3.2 millones de Girl Scouts Membresía vence 9/30/20 Nombre Segundo nombre Apellido/s Dirección Apartamento ( ) Ciudad Estado/Código postal Teléfono del hogar ( ) Me gustaría Mensajes de texto Celular de la niña* Correo electrónico de la niña* optar por: Correos electrónicos *Proporcionar sólo si la niña es mayor de 13 años de edad Girl Scouts respeta y da la bienvenida a todas las personas independientemente de sus orígenes y capacidades. Al completar la siguiente información (tal como define el Censo de los Estados Unidos), usted asegura apoyo y recursos para niñas en su comunidad. Tenga en cuenta que Hispano/Latino se define como etnia, no raza, y por lo tanto es indicado por separado. La recolección de esta información es para exclusivo uso estadístico. Fecha de nacimiento: (día/mes/año) / / # de años como Girl Scout: Grado escolar en Otoño de 2013: Nombre de la escuela a la que pertenece actualmente: Bajo la tutela de: Ambos padres Madre/Tutor legal únicamente Padre/Tutor legal únicamente Otro Dirección igual que la de la niña Ella es: Nativa americana o nativa de Alaska Asiática Negra o afroamericana Hawaiana o de las islas del Pacífico Blanca Otro (especificar) Prefiero no responder por el momento Ella es hispana o latina: Sí No Prefiero no responder por el momento Nombre del padre/madre/tutor legal (1) Segundo nombre Apellido/s Dirección Ingresos familiares: $0 $14,999 $15,000 $34,999 $35,000 $49,999 $50,000 $74,999 $75,000 $99,999 $100,000 o más Prefiero no responder por el momento Lugar de trabajo Título/Ocupación Teléfono del hogar Teléfono del trabajo ( ) Me gustaría Mensajes de texto Celular Correo electrónico optar por: Correos electrónicos Dirección igual que la de la niña Nombre del padre/madre/tutor legal (2) Segundo nombre Apellido/s Dirección Lugar de trabajo Título/Ocupación Teléfono del hogar Teléfono del trabajo ( ) Me gustaría Mensajes de texto Celular Correo electrónico optar por: Correos electrónicos Al participar en actividades de Girl Scouts, puedo ser fotografiada para publicaciones escritas, videos o medios electrónicos. Las imágenes pueden ser usadas en materiales promocionales, anuncios y otros formatos de publicaciones de los concilios de Girl Scouts o de Girl Scouts of the USA. Las imágenes serán de exclusiva propiedad ya sea de los concilios de Girl Scouts o de Girl Scouts of the USA. No autorizo esta oportunidad en este momento. La Ley de Girl Scouts Yo me esforzaré por: ser honrada y justa, cordial y servicial, considerada y compasiva, valiente y fuerte, y responsable de lo que digo y hago, y por respetarme a mí misma y a los demás respetar la autoridad, usar los recursos de manera prudente, hacer del mundo un lugar mejor, y ser hermana de cada una de las Girl Scouts. La Promesa de Girl Scouts Por mi honor, yo trataré: de servir a Dios y a mi patria, ayudar a las personas en todo momento, y vivir conforme a la Ley de Girl Scouts. Reconocemos que mi/ nuestra niña hará la Promesa de Girl Scouts y aceptará la Ley de Girl Scouts. Autorizo que ella se una a Girl Scouts. Firma del padre/tutor legal Firma del padre/tutor legal Al hacer la promesa de Girl Scouts, los miembros individuales pueden sustituir con una redacción adecuada la palabra Dios de acuerdo a sus propias creencias espirituales. Fecha Fecha MISIÓN DE GIRL SCOUTS Girl Scouts ayuda a las niñas a desarrollar el valor, la confianza en sí mismas y los principios para hacer del mundo un lugar mejor. FORMAS DIVERTIDAS DE PARTI- CIPACIÓN: complete junto con la niña (marcando todos los puntos de interes) Campamentos: Conéctate con la naturaleza. Elige un campamento de día o día y noche. Eventos: Disfruta de eventos de medio día o día completo donde compartir tus intereses. Series: Explora tus intereses en unas cuantas sesiones sin que esto interfiera con tu horario de actividades. Viajes: Haz tus maletas. Viaja por tu ciudad o alrededor del mundo! Tropa: Diviértete regularmente con tus hermanas Girl Scouts. Virtual: Comparte y aprende virtualmente con Girl Scouts en todas partes. SÍ! También quiero hacer una donación que beneficie directamente a todas las niñas de mi área. Envío una donación deducible de impuestos por el monto de: (marque donde corresponda). $500 $250 $150 $100 $50 $25 Otro: $ INFORMACIÓN DE PAGO Membresía anual: $ 15 Donación: $ Total adjunto: $ Efectivo Amex Visa Otra Cheque* Discover MasterCard Nombre en la tarjeta de crédito Número de tarjeta Fecha de vencimiento Firma Fecha *Haga el cheque pagadero a Girl Scouts GRACIAS POR APOYAR A GIRL SCOUTS! Para más información acerca de Girl Scouts visita girlscouts.org/espanol PARA USO ADMINISTRATIVO Código de concilio: Unidad de Servicio/Grupo: Grupo/Tropa: FORMA DE PARTICIPACIÓN Campamentos Eventos Series Viajes Tropa Virtual Entregue este formulario de inscripción a su concilio, junto con la cuota de GSUSA. Las cuotas no son reembolsables ni se pueden transferir a otras personas.

6 Adult Membership Join the global network of 3.2 million Girl Scouts Membership Year through 9/30/20 GIRL SCOUT MISSION Girl Scouting builds girls of courage, confidence, and character, who make the world a better place. Check one: New Member Renewing Member Lifetime Member GSUSA ID (if known) GET INVOLVED PARTICIPATION DEMOGRAPHICS CONTACT INFORMATION ACCEPTANCE Title or salutation: Mrs. Ms. Miss Mr. Dr. Other: Name: First Middle Last Address Apartment City State Zip Code Home Phone Business Phone ( ) I wish to opt in: Texts s Cell Phone Address Employer Title/Occupation Girl Scouts respects and welcomes people from all backgrounds and abilities. By completing the following information (as defined by the US Census), you ensure support and funding for girls in your community. Hispanic/Latina is defined as an ethnicity, not a race, therefore reported separately. This information is used for statistical purposes only. Gender: Female Male Highest education: (check one) Some High School High School Some College Associate Degree Bachelor Degree Postgraduate Degree # of years in Girl Scouting: as a girl: as an adult: I am: (check all that apply) American Indian or Alaskan Native Asian Black or African American Hawaiian or Pacific Islander White Other (please specify) I choose not to share at this time I will be participating in Girl Scouting as: (check all that apply) Volunteer I am/will be volunteering for Girl Scouts Parent/Family I am a parent/guardian/family member of a Girl Scout Girl Scout Alumnae I was a Girl Scout, either as a girl, adult or both of birth: / / mm dd yyyy I am Hispanic or Latina: Yes No I choose not to share at this time Age range: and up Household income: $0 $14,999 $15,000 $34,999 $35,000 $49,999 $50,000 $74,999 $75,000 $99,999 $100,000 or more I choose not to share at this time Community Partner Staff I am/will be employed by Girl Scouts Other As a volunteer, I would like to participate in the following role(s): Representing Group(s)/Troop(s)/Service Unit Numbers: 01 Advisor or Leader for a Group/Troop # # # # 02 Assistant Advisor or Leader for a Group/Troop Advisor/Leader # # # 03 Support Volunteer for a Group/Troop # # # 11 Service Team or Unit Volunteer SU SU SU 12 Learning Facilitator Other (specify) PARTICIPATE WITH GIRLS DIRECTLY: (check all that interest you) Camp: Help girls connect with nature during day or overnight camp. Events: Share your passions during half or full day events. Series: Share your interests in a way that fits your schedule Travel: Expand girls horizons. Travel with girls across town or around the world! Troop: Inspire and develop a group of girls on a regular basis. Virtual: Interact virtually with Girl Scouts everywhere. Media Permission When participating in Girl Scout activities I may be photographed for print, videotaped, or electronically imaged. Images may be used in promotional materials, news releases, and other published formats for either the local Girl Scout Councils or Girl Scouts of the USA. The images will be the sole property of either the local Girl Scout Council or Girl Scouts of the USA. I wish to opt out at this time. The Girl Scout Law I will do my best to be honest and fair, friendly and helpful, considerate and caring, courageous and strong, and responsible for what I say and do, and to respect myself and others, respect authority, use resources wisely, make the world a better place, and be a sister to every Girl Scout. GET INVOLVED BEHIND-THE-SCENES : (check all that interest you) Administrative: Manage, support and recognize volunteers in your community Council Committees: Assist in council-wide Girl Scouts operations Learning Facilitator: Coordinate learning opportunities Fund Development: Promote and advance the Girl Scout movement through family and corporate donations The Girl Scout Promise On my honor, I will try: To serve God and my country, To help people at all times, And to live by the Girl Scout Law. When making the GS Promise, individual members may substitute wording appropriate to their own spiritual beliefs for the word God. I accept and abide by the Girl Scout Promise and Law: Signature MEMBERSHIP OPTIONS: Annual Membership Annual fee: $15 Lifetime Membership (including permanent membership card and recognition certificate) One time fee of $375: Adults 18 years of age or older One time fee of $195: Girl Scout Ambassadors graduating from High School in this membership year in the month of: (please submit by Sept. 1st of graduating year) YES! I would also like to make a donation today that directly benefits girls in our area. Enclosed is my tax-deductible donation in the amount of: (check one) $500 $250 $150 $100 $50 $25 Other: $ PAYMENT INFORMATION: Annual Membership: $ Lifetime Membership: $ Donation: $ Total Attached: $ Cash Check* Amex Discover Visa MasterCard Other Name on Credit Card Credit Card # Expiration Signature *Make checks payable to Girl Scouts THANK YOU FOR SUPPORTING GIRL SCOUTS! Learn more about Girl Scouts at ADMIN USE ONLY: Council Code: Service Unit/Team: Group/Troop: Return this registration form, along with GSUSA annual membership fee or applicable Lifetime fee to your local council. Fees are non-refundable or transferable to another person.

7 Título: Sra. Srta. Sr. Dr. Otro: Nombre Segundo nombre Apellido/s Dirección Apartamento Ciudad Estado Código postal Teléfono Teléfono del trabajo ( ) Me gustaría Mensajes de texto Celular Correo electrónico optar por: Correos electrónicos Lugar de trabajo Título/Ocupación Girl Scouts respeta y da la bienvenida a todas las personas independientemente de sus orígenes y capacidades. Al completar la siguiente información (tal como define el Censo de los Estados Unidos), usted asegura apoyo y recursos para niñas en su comunidad. Tenga en cuenta que Hispano/Latino se define como etnia, no raza, y por lo tanto es indicado por separado. La recolección de esta información es para exclusivo uso estadístico. Género: Femenino Masculino Nivel más alto de educación: Algo de escuela secundaria Escuela secundaria completa Ciertos cursos universitarios Diploma universitario Licenciatura universitaria Educación de posgrado # de años como Girl Scout: como niña/jovencita: como adulto: Me identifico como: Nativo/a americano/a o nativo/a de Alaska Asiático/a Negro/a o afroamericano/a Hawaiano/a o de las islas del Pacífico Blanco/a Otro (especificar) Prefiero no responder por el momento Participaré en Girl Scouts como: (marque las opciones que califican) Voluntario/a Soy o seré voluntario/a en Girl Scouts Padre/Madre/Familiar soy padre/madre/tutor legal/familiar de una Girl Scout Ex-alumna He participado con Girl Scouts, ya sea como niña, adulta, o ambas. Fecha de nacimiento: / / día mes año Soy hispano/a o latino/a Sí No Prefiero no responder por el momento Edad: Mayor de 50 años Ingresos familiares: $0 $14,999 $15,000 $34,999 $35,000 $49,999 $50,000 $74,999 $75,000 $99,999 $100,000 o más Prefiero no responder por el momento Colaborador/a comunitario/a Empleado/a soy empleado/a de Girl Scouts Otro Como voluntario/a, deseo participar como: Grupo(s)/Tropa(s)/ Unidades de Servicio #: 01 Asesor o Líder de Grupo/Tropa # # # 02 Asistente del Asesor o del Líder de Grupo/Tropa # # # 03 Voluntario de Apoyo para Grupo o Tropa # # # 11 Voluntario de Grupo o Unidad de Servicio SU SU SU 12 Facilitador de Aprendizaje SU (Unidad de Servicio) Otro (especifique) PARTICIPE CON LAS NIÑAS EN FORMA DIRECTA: (marque todos sus intereses) Campamentos: Ayude a las niñas a conectarse con la naturaleza durante el día o acompañándolas durante una noche de campamento. Eventos: Comparta sus intereses y conocimientos con las niñas durante un evento de medio día o día completo. Series: Invierta tiempo en las niñas sin que esto interfiera con su horario de actividades. Viajes: Expanda el horizonte de las niñas. Viaje con ellas por la ciudad o alrededor del mundo! Tropa: Inspire y desarrolle un grupo de niñas de manera continua. Virtual: Interactúe virtualmente con Girl Scouts de todas partes. Al participar en actividades de Girl Scouts, puedo ser fotografiada para publicaciones escritas, videos o medios electrónicos. Las imágenes pueden ser usadas en materiales promocionales, anuncios y otros formatos de publicaciones de los concilios de Girl Scouts o de Girl Scouts of the USA. Las imágenes serán de exclusiva propiedad ya sea del concilio de Girl Scouts al cual pertenezco o de Girl Scouts of the USA. No autorizo esta oportunidad en este momento. La Ley de Girl Scouts Yo me esforzaré por: ser honrada y justa, cordial y servicial, considerada y compasiva, valiente y fuerte, y responsable de lo que digo y hago, y por respetarme a mí misma y a los demás respetar la autoridad, usar los recursos de manera prudente, hacer del mundo un lugar mejor, y ser hermana de cada una de las Girl Scouts. Membresía para adultos Tipo de membresía: Nueva membresía Renovación de membresía Membresía vitalicia GSUSA ID (si lo sabe) INVOLÚCRESE PARTICIPACIÓN DATOS DEMOGRÁFICOS INFORMACIÓN PERSONAL COMPROMISO Únase a nuestra red mundial de 3.2 millones de Girl Scouts Membresía vence 9/30/20 OTRAS FORMAS DE PARTICIPACION: (seleccione todas las que correspondan) Administración: Dirija, apoye e invite a otras personas a participar como voluntarios en su comunidad Comités del concilio: Colabore en las operaciones del concilio Facilitador de Aprendizaje: Coordine oportunidades de aprendizaje Desarrollo/Colecta de Fondos: Promueva e impulse el movimiento Girl Scouts mediante donaciones familiares y corporativas La Promesa de Girl Scouts Por mi honor, yo trataré: de servir a Dios y a mi patria, ayudar a las personas en todo momento, y vivir conforme a la Ley de Girl Scouts. Acepto y cumpliré con la Promesa y la Ley de Girl Scouts. Firma Al hacer la promesa de Girl Scouts, los miembros individuales pueden sustituir con una redacción adecuada la palabra Dios de acuerdo a sus propias creencias espirituales. Fecha MISIÓN DE GIRL SCOUTS Girl Scouts ayuda a las niñas a desarrollar el valor, la confianza en sí mismas y los principios para hacer del mundo un lugar mejor. OPCIONES DE MEMBRESÍA Membresía anual Cuota anual: $15 Membresía vitalicia (Incluirá credencial que lo/la identifique como miembro vitalicio y un certificado de reconocimiento). Cuota única de $375: Disponible para adultos mayores de 18 años. Cuota única de $195. Disponible para Girl Scouts Ambassadors que se graduarán de la escuela secundaria durante el año de membresía, en el mes de. (Debe enviarse este formulario antes del 1 de septiembre del año en curso). SÍ! También quiero hacer una donación que beneficie directamente a las niñas de mi área. Envío una donación deducible de impuestos por el monto de: (marque donde corresponda) $500 $250 $150 $100 $50 $25 Otro: $ INFORMACIÓN DE PAGO Membresía anual: $ 15 Membresía vitalicia: $ Donación: $ Total adjunto: $ Efectivo Amex Visa Otra Cheque* Discover MasterCard Nombre en la tarjeta de crédito Número de tarjeta Fecha de vencimiento Firma Fecha *Haga el cheque pagadero a Girl Scouts GRACIAS POR APOYAR A GIRL SCOUTS! Para más información acerca de Girl Scouts visite PARA USO ADMINISTRATIVO Código de concilio: Unidad de Servicio/Grupo: Grupo/Tropa: Entregue este formulario de inscripción a su concilio, adjuntando la cuota anual de GSUSA o el pago vitalicio. Las cuotas no son reembolsables ni se pueden transferir a otras personas.

8 COUNCIL PROGRAM REGISTRATION Mail or deliver this form to any of the five Girl Scouts of Greater South Texas service centers. This registration form will be returned unprocessed to you: if full payment does not accompany the form; if the form is incomplete or inaccurate; or if registration for the event listed is not yet open. If the registration form is returned to you, your spot at the event is not held. Refer to the program guide In Motion for additional information regarding registration and refunds. SUBMIT ONE FORM AND PAYMENT PER PROGRAM Event Name: Event : Event Location: Person to receive confirmation: Troop SU Address City, ZIP Phone ( ) Can we send your welcome packet by to save paper? Yes No Indicate whether this is an individual registration or a troop/group registration: Individual Troop/Group PAYMENT BY CREDIT CARD REGISTRATION FEES Event fee per participant # of Participants Girl / Child $ $ Adult $ $ PAYMENT MUST ACCOMPANY THIS FORM. Total Payment $ Total Please charge my: Visa MC Discover Credit Card # Exp. Billing Zip code Security / V-Code Print your name as it appears on your card: Signature Troop Registrations only (all items must be checked): I understand that participating troops must provide Essential Safety Adults (ESAs) to meet the girl/adult safety ratio unless otherwise noted in the program guide, In Motion. One or more of the Essential Safety Adults must be a First Aider with current First Aid and CPR certification. Copies of certifications must be submitted with each council program registration form. I understand that drivers for troop trips must be registered Girl Scout members and submit current copies of insurance and driver s license with each council program registration form. The leader will have a signed permission slip with photo permission and health history form for each girl in the troop/group on hand during the event. I have read and agree with the program information and the council s refund procedure. Individual Registrations only (all items must be checked): A parent/guardian of my daughter/ward will be present at the event to supervise her, unless the event was designated as a Drop Off event in the program guide. I have read and agree with the program information and the council s refund procedure and give my daughter/ward permission to attend this event. I understand that photographs of participants at this event are the property of the Girl Scouts of Greater South Texas and may be used for publicity purposes including print and online media, and council publications. Leader/Volunteer or Parent Signature PAGE 1 OF 2 OFFICE USE: Fee Amount Rec d by Conf.

9 COUNCIL PROGRAM REGISTRATION Mail or deliver this form to any of the five Girl Scouts of Greater South Texas service centers. Participation Roster List each girl / child attending Girl / Child First and Last Name Grade Special Accommodations/Needs List the Essential Safety Adults attending, and any additional adults serving in the following capacities: Adults First and Last Name Leader Driver (Ins & DL) First Aider (FA&CPR cert.) DRIVERS must have current Insurance and driver s license attached to registration form. FIRST AIDERS must have current First Aid & CPR certification attached to registration form. PAGE 2 OF 2 Use an additional sheet if needed.

10 SECTION A: MEMBER INFORMATION Confidential Health History This form must be completed and signed by parents/guardians of girls or by adult members themselves. All health history forms will be held in limited access by the trustee (leader/facilitator/staff) of the specific Girl Scout program. The absolute minimal necessary information may be shared with program staff/volunteers in order to provide adequate care. The health history form will be retained by the Girl Scout program trustee until it is destroyed. This form must be signed. Duplicate this form as needed. Name of Birth Age Troop # Address City, ZIP Parent/Guardian Phone ( ) Home Address City, ZIP Business Phone ( ) Home Phone ( ) If Parent/Guardian is unavailable, contact: Relationship: Address Phone ( ) Name of Family Physician: Phone ( ) Insurance Carrier: ID Number Insurance Carrier s Contact Phone Number ( ) SECTION B: HEALTH HISTORY / RECURRING CONDITIONS / MEDICATION PERMISSIONS Check each applicable item, giving appropriate dates and comments. ALLERGIES / DESCRIPTION Foods Insects Plants Drugs Animals Hay fever Asthma Latex Other ADDITIONAL INFORMATION Operation/ Serious Injury/ Sleepwalking Bedwetting Fainting Constipation Night Disturbances of last health examination / / Were any complicating medical problems noted? Is participant now under the care of a physician / psychologist? List restrictions to swimming, diving, running, etc. Describe any medical/dietary regimen to be continued: RECURRING CONDITIONS Ear Infections Heart Disease Kidney Disease Convulsions Bronchitis Frequent Colds Frequent Sore Throat Stomach Upset Diabetes Hyperactivity Epilepsy Hearing Impairment Vision Impairment Orthopedic Impairment Learning Disability Other Since last health examination, has the participant had: A serious illness requiring medical attention? An illness lasting more than 5 days? A surgical operation or fracture? Treatment in a hospital or emergency room? Any restrictions concerning physical activities? Exposure to a contagious disease? Within the past month? What? DISEASES / DATES Chicken Pox Measles German Measles Mumps Scarlet Fever Rheumatic Fever Poliomyelitis Whooping cough Other OVER-THE-COUNTER MEDICATION PERMISSIONS My daughter/ward has permission to take or use the following upon recommendation by a First Aider: Acetaminophen Ibuprofen Decongestant Antihistamine oral or cream Anti-diarrheal liquid or tablets Antacid tablets Expectorant Alcohol-vinegar solution ear drops Other SECTION C: PARENT/GUARDIAN MUST COMPLETE THE INFORMATION BELOW I have read the procedures for handling my daughter/ward s health history information and I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. In case of emergency, I give permission for the First Aider(s) to administer medication and/or First Aid AND give permission to an attending physician to hospitalize or secure proper treatment/surgery for me/my child. I give permission to transport me/my child to the nearest emergency facility for treatment. I know of no reason(s), other than the information indicated on this form, why I/my child should not participate in prescribed activities except as noted. Signature of parent/guardian

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