Ptanka Rogers Service Unit 898 Girl Scouts of Ohio s Heartland Service Unit Events Registration Packet

Transcription

1 Ptanka Rogers Service Unit 898 Girl Scouts of Ohio s Heartland Service Unit Events Registration Packet

2 Dear Northern Columbus Girl Scouts Family, This year we here at the Ptanka (Pu-tonka) Rogers Service Unit are trying to make it as simple as possible to register for our many wonderful Service Unit events. You can see the full list, download an Academic Calendar, and view the flyers on our web site at So what s new in ? Cheaper events Service Unit events on days when schools are closed (Columbus City Schools) More badge work All Troop Meetings open to every Girl Scout with or without her troop, including IRGs (Independently Registered Girl Scouts) Longer, more cooking-intense Mother-Daughter Retreat in Yurts (You talked, we listened!) New Year s Eve Party for girls, so you don t have to worry about childcare Spring Break Day Camp Uniform Exchange Volunteering to off-set participation cost (limited availability) Much more!!! There are two ways to complete this packet. You can either print it out, complete it, and mail it to: Anna L. Winders, Ptanka Rogers, 4805 McFadden Road, Columbus, OH OR you can download it, Fill and Sign, save, and it to Manager@PtankaRogers.org. What s awesome about this? This is the one and only time the Service Unit will ask you to complete forms to participate! The forms have been adjusted to include every date of a Service Unit event so no more constantly needing to complete registration forms, health forms, and photo releases! How can you pay for events? You can include a check or money order with your registration payable to Ptanka Rogers Service Unit OR you can request an invoice be sent to you via . Invoices sent through , can be paid with a debit/credit card and will incur a 5% service fee. (Participation in every single event totals $285. So, for example, the fee for this amount would be $14.25 for a total of $299.25) Please note that volunteers are absolutely needed for every single Service Unit event. In fact, if you would like to volunteer but running a Troop is not for you, then this is the perfect way to volunteer! Service Unit Events (including All Troop Meetings) are completely planned out. We just need volunteers like you who are willing to help with transportation and help the girls during the event! Volunteers must be current Adult Girl Scout Members, complete an online background check every 3 years, complete 2 short webinars, and complete 1 face-to-face Volunteer Essentials Class. There is one being offered at Karl Road Library on July 30. Check CORA for registration!

3 Please review the events below and if you think you and/or your daughter will be/would like to be in attendance at the event, please complete the form as stated. If you have any questions or concerns, please feel free to me at In addition, if you would like to stay up -to-date on service unit events, download the academic calendar, etc. please visit our web site at Family Last Name Troop #/IRG/Seeking Troop Address for Contact I would like to get more information about volunteering in exchange for Service Unit Event participation funding. Girl Scout Name (List children and adults participating in Ptanka Rogers Service Unit events) Girl Scout Troop # IRG or Seeking Troop Place an X in the Box ONLY if you DO NOT allow photos ALLERGIES/ DIETARY RESTRICTION/ SEVERE HEALTH CONDITIONS (JUST LIST AS SU MMARY) INDICATE POSSESSION OF EPIPEN, INHALOR, C -PAP, OR OTHER MEDICAL DEVICES

4 Abbreviations: D (Daisy Grades K-1) B (Brownie Grades 2-3) J (Junior Grades 4-5) C (Cadette Grades 6-8) S (Senior Grades 9-10) Am (Ambassador Grades 11-12) Ad (Adult) *** Please Note: Until Confirmation and Payment have been received for events, spots will not be reserved for participants indicated below. When possible (events in and after September 2016), a confirmation request will be sent to you for the event. Payment can be received no later then 5 weeks prior to event as GSOH requires payment in full in this time frame. These events (except Volunteer training on 7/30) are not available for registration on CORA because they are Service Unit events and not Council Wide events. Date and Time of Event Event Cost (Unless otherwise noted, cost for adult and girl is same) Event Description How many girls or adults will be attending in each level? D B J C S Am Ad 7/8/16 6:30-8pm 7/30/16 9a-6p 8/12/16 6:30-8pm 8/27/16 1-5pm 9/9/16 6:30-8pm 9/23 7a-6p FREE FREE All Troop Meeting: Karl Road Christian Church, 5400 Karl Road Badge Focus: Artist Part 1 (Legacy) Volunteer Training Badge Focus: Artist Part 2 (Legacy) FREE Fall in Love with Girl Scouts Woodward Park Recreation Center Side Lawn Area Explore the Journeys, Make SWAPS, Get registered On Time Badge Focus: Girl Scout Way Part 1 (Legacy) $15 NO SCHOOL CCS: Corn Maze Cost includes all ac tivities, picnic lunch, snacks, and patch 9/23-9/25 $49 New Leader Retreat Get ready to be a leader and have all your questions answered! Cost includes all ac tivities, training, lodging, and meals. 10/14 6:30-8pm 10/26 7a-6p 11/8 7a-6p 11/11 6:30-8p 12/9 6:30-8p 12/31-1/1 8p-10a 1/13 6:30-8pm 1/13-1/15 6p-11a Badge Focus: Girl Scout Way Part 2 (Legacy) $15 NO SCHOOL CCS: First Aid Badge (Legacy) Planned venue is Karl Road Christian Church but waiting on confirmation. Cost includes supplies, patch, lunch $15 NO SCHOOL CCS: Citizenship Badge (Legacy) Planned venue is Karl Road Christian Church but waiting on confirmation. Cost includes supplies, patch, lunch Badge Focus: Healthy Living Par t 1 (It s Your World) Badge Focus: Healthy Living Par t 2 (It s Your World) $20 New Year s Eve Party Venue Pending Cost includes supplies, snacks, lodging, breakfast, and patch Badge Focus: Manners Part 1 (It s Your Story) $80 (pair) Mother Daughter KJ Yurts Cost includes lodging, snacks, 5 patches for each adult and girl, activities ($5 per enrollment discount when paid by 11/18)

5 D B J C S Am Ad 2/10 6:30-8pm 2/20 7a-6p 3/10 6:30-8pm 3/12 $15/girl $5/adult $8/extra child 4/14 FREE 6:30-8p 4/17-4/21 7a-6p 5/12 6:30-8p 5/27 10a-5p 6/9 7a-6p 6/9 6:30-8p 7/4 9a-1p 7/14 7a-6p 7/14 6:30-8p Badge Focus: Manners Part 2 (It s Your Story) $10 NO SCHOOL CCS: World Thinking Day Event Planned venue is Karl Road Christian Church but waiting on confirmation. Cost includes supplies, patch, lunch Badge Focus: Athlete Part 1 (Legacy) $100/ week FREE Girl Scout Birthday Party: Worthington A thletic Center Plans to be finalized on 12/1: Tentative Time 1p-5p Cost includes room rental, birthday cake, astronaut ice cream, 4 hours indoor swimming access All Troop Meeting: Karl Road Christian Church, 5400 Karl Road Badge Focus: Athlete Part 2 (Legacy) NO SCHOOL CCS: Spring Break Day Camp Planned venue is Karl Road Christian Church but waiting on confirmation. Cost includes supplies, patches and badges, lunches All Troop Meeting: Karl Road Christian Church, 5400 Karl Road Badge Focus: Outdoors Part 1 (It s Your Planet) $15 Service Unit Day with Bridging Ceremony, Archery, Canoeing KJ Cost includes all ac tivities, Early Bird Patch, Archery Patch, Canoeing Patch, Bridging Ceremony Refreshments $5 Highbanks Day: Naturalist Badge Cost includes program materials and Naturalist badge FREE FREE All Troop Meeting: Karl Road Christian Church, 5400 Karl Road Badge Focus: Outdoors Part 2 (It s Your Planet) Northland Independence Day Parade Float $15 Herstory Day: Learn about the history and traditions of Girl Scouts. Planned venue is Karl Road Christian Church but waiting on confirmation. Cost includes supplies, patch, lunch On-Time open House and Early Birds Award Ceremony SUBTOTAL COST TOTAL YEAR ADD 5% AND PAY VIA DEBIT/CREDIT AND ED INVOICE ADD 0% CHECK ENCLOSED *NOTE DATE CHECKS FOR DAY YOU WISH THEM TO BE DEPOSITED TOTAL DUE GIRL (S) ADULT (S) GIRL(S) + ADULT(S)

6 Health History, Emergency Contact Information, Permission to treat with First Aid and Medical Authorization Name of Child Street Address City, State ZIP Parent/Guardian 1 Day Phone P/G1 Evening Phone P/G 1 Parent/Guardian 2 Day Phone P/G2 Evening Phone P/G2 Emergency Contact Name Relationship to Child Day Phone EC Evening Phone EC PLEASE FILL OUT EITHER SECTION ONE (CONSENT FOR MEDICAL TREATMENT) OR SECTION TWO (REFUSAL OF CON- SENT FOR TREATMENT). THE REVERSE SIDE OF THIS FORM CONTAINS MEDICAL HISTORY INFORMATION WHICH SHOULD BE COMPLETED AND ACKNOWLEDGED BY THE PARENT OR GUARDIAN OF THE MINOR CHILD. Section 1 Authorization to permit medical treatment. By signing below, I hereby give permission t o the Girl Scouts of Ohio s Heartland Council, Inc. (Girl Scouts), their employees, members, or volunteers to provide routine first aid and to supervise self-medication and to seek medical assistance on behalf of my child in the event my child is injured or becomes ill, and I am unavailable to indica te my wishes regarding treatment. I understand that the Girl Scouts and its members, volunteers, or employees shall not be held responsible for the cost of treatment, and in fact are authorized to bind me as the financially responsible party for the med ical treatment of my child. I hereby grant permission to physicians and other licensed health care providers and their designees to administer medical care through injury or illness evaluation, first aid care, and referral to duly licensed medical personnel when indicated. I AUTHORIZE THE RELEASE OF ALL INFORMATION ON THE REVERSE TO TREATMENT PROVIDERS, AND WILL HOLD THE GIRL SCOUTS IN NO WAY RESPONSIBLE FOR THE RELEASE OF THIS INFORMATION TO ANY PARTY. 6/30/16-6/30/17 Parent Signature Date Signed Medical Insurance Provider Valid For

7 Section 2 Refusal to consent to medical treatment. By signing below, I indicate that the Girl Scouts of Ohio s Heartland Council, Inc. (Girl Scouts), its volunteers, or employees are not authorized to allow the administration of health care to my child in the event of injury or sickness. However, I will not hold the Girls Scouts, its employees, members, or volunteers liable in any way for seeking emergency care (such as calling 911) for my child or providing any health information on this form to emergency personnel. 6/30/16-6/30/17 Parent Signature Date Signed Medical Insurance Provider Valid For MEDICAL HISTORY INFORMATION MUST BE COMPLETED REGARDLESS OF MEDICAL CARE ACCEPTANCE/DENIAL. Health History: Y or N: Explain any Ys Frequent Ear Infections Frequent Headaches Heart Defect/Disease Convulsions Seizures Diabetes Bleeding/Clotting Disorders Hypertension Mononucleosis (in the past year) Musculoskeletal Disorders Allergies Specify Allergen/N Allergy Type Reaction Type and Treatment Animal Hay Fever Poison Ivy Insects Penicillin Medication Food Does child have and know how to use an EpiPen? Health Conditions (Y/N) Bed Wetting Emotional Disturbances Hearing Impairment Dietary Restrictions Fear of Storms Vision Impairment Sleepwalking Asthma Diseases ( Y or N; If Y give dates) Chicken Pox Measles Mumps Hepatitis Immunization (Give last date given) DATE (mm/yy) VACCINE DTaP Tdap Booster Polio MMR Hib Hep B Varicella (pox) TB Test (Indicate +/-) Please provide any information useful to the adult in charge in relation to any of these health conditions. Also, indicate an y activities to be encouraged or restricted by physician or any special dietary needs. (Use Additional Sheet If Necessary) 6/30/16-6/30/17 Parent Sign ature Date Signed Valid Fo r

8 JG Revised 9/12 Global/Public Relations/Photo Release Forms Girl Scouts of Ohio's Heartland 1700 WaterMark Drive Columbus, OH gsoh.org DATES 2016 (8/12, 8/27, 9/9, 9/23, 10/14, 10/26,11/8, 11/11, 12/9, 12/31) 2017 (1/1, 1/13, 1/14, 1/15, 2/10, 2/20, 3/10, 3/12, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 5/12, 5/27, 6/9, 7/4, 7/14) PHOTOGRAPHER/PRODUCER Ptanka Rogers Service Unit 898 ASSIGNMENT Service Unit Events COUNCIL LOCATION ACTIVITY Girl Scouts of Ohio s Heartland Various Various Service Unit Events RELEASE FOR MINORS For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent and agree to the following: 1. I hereby grant to Girl Scouts of Ohio s Heartland, ( GSOH ), and others working for GSOH or on its behalf, and each of its respective licensees, successors and assigns (each a Releasee ), the irrevocable, royalty-free, perpetual, unlimited right and permission to use, distribute, publish, exhibit, digitize, broadcast, display, modify, create derivative works of, reproduce or otherwise exploit my name, picture, likeness and voice (including any video footage of the same) (collectively, Media ), or to refrain from so doing, anywhere in the world, by any persons or entities deemed appropriate by GSOH, for any purpose (except defamatory) including, without limitation, any use for educational, advertising, non-commercial or commercial purposes in any manner or media whatsoever (whether known or hereafter devised) including, without limitation, on the internet, in print campaigns, in-store and via television. I agree that I have no interest or ownership in any of the Media. 2. I shall have no right of approval, no claim to compensation and no claim (including, without limitation, claims based upon invasion of privacy, defamation or right of publicity) arising out of any use, alteration, blurring, illusionary effect or use in any composite form of my name, picture, likeness and voice. I agree that nothing in this Release will create any obligation on GSOH to make any use of the Media or the rights granted in this Release. I hereby release and hold harmless Releases from any claim for injury, compensation or negligence resulting or arising from any activities authorized by this Release and any use of the Med ia by GSOH. Name of Child Child D.O.B. Street Address City, State ZIP Parent/Guardian Name Parent/Guardian Phone Parent/Guardian (not for release to 3rd parties) Parent Signature Date Signed Release for Minors (those under the age of eighteen): I, having signed this release, being a parent or guardian of the minor, hereby consent to the foregoing conditions and warrant that I have the authority to give such consent. Any revisions to the text of this Release must be approved in writing by GSOH prior to the activity in order for the changes to be effective. PLEASE RETURN COMPLETED AND SIGNED RELEASE TO AUDIO/VIDEO SERVICES, GSOH

9 Adult Forms These must also be completed for participation. Again, these forms will be kept on file for the full year so you only need to complete them one time. Two versions of the adult forms are supplied in this packet. If you need more than two adult forms for your family, please download or print another packet and fill out just the information for the adults and send it in with your initial packet.

10 Health History, Emergency Contact Information, Permission to treat with First Aid and Medical Authorization Name of Adult Street Address City, State ZIP Emergency Contact 1 Relationship of EC1 Day Phone EC1 Evening Phone EC1 Emergency Contact 2 Relationship of EC2 Day Phone EC2 Evening Phone EC2 PLEASE FILL OUT EITHER SECTION ONE (CONSENT FOR MEDICAL TREATMENT) OR SECTION TWO (REFUSAL OF CONSENT FOR TREATMENT). Section 1 Authorization to permit medical treatment. By signing below, I hereby give permission t o the Girl Scouts of Ohio s Heartland Council, Inc. (Girl Scouts), their employees, members, or volunteers to provide routine first aid and to supervise self-medication and to seek medical assistance on behalf of myself in the event I am injured or becomes ill, and my Emergency Contacts are unavailab le to indicate my wishes regarding treatment. I understand that the Girl Scouts and its members, volunteers, or employees shall not be held responsible for the cost of treatment, and in fact are authorized to bind me as the financially responsible party for th e medical treatment of myself. I hereby grant permission to physicians and other licensed health care providers and their designees to administer medical care through injury or illness evaluation, first aid care, and referral to duly licensed medical personnel when indicated. I AUTHORIZE THE RELEASE OF ALL INFORMATION ON THE REVERSE TO TREATMENT PROVIDERS, AND WILL HOLD THE GIRL SCOUTS IN NO WAY RESPONSIBLE FOR THE RELEASE OF THIS INFORMATION TO ANY PARTY. 6/30/16-6/30/17 Adult Signature Date Signed Medical Insurance Provider Valid For

11 Section 2 Refusal to consent to medical treatment. By signing below, I indicate that the Girl Scouts of Ohio s Heartland Council, Inc. (Girl Scouts), its volunteers, or employees are not authorized to allow the administration of health care to myself in the event of injury or sickness. However, I will not hold the Girls Scouts, its employees, members, or volunteers liable in any way for seeking emergency care (such as calling 911) for my child or providing any health information on this form to emergency personnel. 6/30/16-6/30/17 Adult Signature Date Signed Medical Insurance Provider Valid For MEDICAL HISTORY INFORMATION MUST BE COMPLETED REGARDLESS OF MEDICAL CARE ACCEPTANCE/DENIAL. Health History: Y or N: Explain any Ys Frequent Ear Infections Frequent Headaches Heart Defect/Disease Convulsions Seizures Diabetes Bleeding/Clotting Disorders Hypertension Mononucleosis (in the past year) Musculoskeletal Disorders Allergies Specify Allergen/N Allergy Type Reaction Type and Treatment Animal Hay Fever Poison Ivy Insects Penicillin Medication Food Does child have and know how to use an EpiPen? Health Conditions (Y/N) Bed Wetting Emotional Disturbances Hearing Impairment Dietary Restrictions Fear of Storms Vision Impairment Sleepwalking Asthma Diseases ( Y or N; If Y give dates) Chicken Pox Measles Mumps Hepatitis Immunization (Give last date given) DATE (mm/yy) VACCINE DTaP Tdap Booster Polio MMR Hib Hep B Varicella (pox) TB Test (Indicate +/-) Please provide any information useful to the adult in charge in relation to any of these health conditions. Also, indicate an y activities to be encouraged or restricted by physician or any special dietary needs. (Use Additional Sheet If Necessary) 6/30/16-6/30/17 Adult Sign ature Date Signed Valid Fo r

12 JG Revised 9/12 Global/Public Relations/Photo Release Forms Girl Scouts of Ohio's Heartland 1700 WaterMark Drive Columbus, OH gsoh.org DATES 2016 (8/12, 8/27, 9/9, 9/23, 10/14, 10/26,11/8, 11/11, 12/9, 12/31) 2017 (1/1, 1/13, 1/14, 1/15, 2/10, 2/20, 3/10, 3/12, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 5/12, 5/27, 6/9, 7/4, 7/14) PHOTOGRAPHER/PRODUCER Ptanka Rogers Service Unit 898 ASSIGNMENT Service Unit Events COUNCIL LOCATION ACTIVITY Girl Scouts of Ohio s Heartland Various Various Service Unit Events RELEASE FOR ADULTS For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent and agree to the following: 1. I hereby grant to Girl Scouts of Ohio s Heartland, ( GSOH ), and others working for GSOH or on its behalf, and each of its respective licensees, successors and assigns (each a Releasee ), the irrevocable, royalty-free, perpetual, unlimited right and permission to use, distribute, publish, exhibit, digitize, broadcast, display, modify, create derivative works of, reproduce or otherwise exploit my name, picture, likeness and voice (including any video footage of the same) (collectively, Media ), or to refrain from so doing, anywhere in the world, by any persons or entities deemed appropriate by GSOH, for any purpose (except defamatory) including, without limitation, any use for educational, advertising, non-commercial or commercial purposes in any manner or media whatsoever (whether known or hereafter devised) including, without limitation, on the internet, in print campaigns, in-store and via television. I agree that I have no interest or ownership in any of the Media. 2. I shall have no right of approval, no claim to compensation and no claim (including, without limitation, claims based upon invasion of privacy, defamation or right of publicity) arising out of any use, alteration, blurring, illusionary effect or use in any composite form of my name, picture, likeness and voice. I agree that nothing in this Release will create any obligation on GSOH to make any use of the Media or the rights granted in this Release. I hereby release and hold harmless Releases from any claim for injury, compensation or negligence resulting or arising from any activities authorized by this Release and any use of the Med ia by GSOH. Name of Adult Adult D.O.B. Street Address City, State ZIP Phone (not for release to 3rd parties) Adult Signature Date Signed I, having signed this release, hereby consent to the foregoing conditions and warrant that I have the authority to give such consent. Any revisions to the text of this Release must be approved in writing by GSOH prior to the activity in order for the changes to be effective. PLEASE RETURN COMPLETED AND SIGNED RELEASE TO AUDIO/VIDEO SERVICES, GSOH

13 Health History, Emergency Contact Information, Permission to treat with First Aid and Medical Authorization Name of Adult Street Address City, State ZIP Emergency Contact 1 Relationship of EC1 Day Phone EC1 Evening Phone EC1 Emergency Contact 2 Relationship of EC2 Day Phone EC2 Evening Phone EC2 PLEASE FILL OUT EITHER SECTION ONE (CONSENT FOR MEDICAL TREATMENT) OR SECTION TWO (REFUSAL OF CONSENT FOR TREATMENT). Section 1 Authorization to permit medical treatment. By signing below, I hereby give permission t o the Girl Scouts of Ohio s Heartland Council, Inc. (Girl Scouts), their employees, members, or volunteers to provide routine first aid and to supervise self-medication and to seek medical assistance on behalf of myself in the event I am injured or becomes ill, and my Emergency Contacts are unavailab le to indicate my wishes regarding treatment. I understand that the Girl Scouts and its members, volunteers, or employees shall not be held responsible for the cost of treatment, and in fact are authorized to bind me as the financially responsible party for th e medical treatment of myself. I hereby grant permission to physicians and other licensed health care providers and their designees to administer medical care through injury or illness evaluation, first aid care, and referral to duly licensed medical personnel when indicated. I AUTHORIZE THE RELEASE OF ALL INFORMATION ON THE REVERSE TO TREATMENT PROVIDERS, AND WILL HOLD THE GIRL SCOUTS IN NO WAY RESPONSIBLE FOR THE RELEASE OF THIS INFORMATION TO ANY PARTY. 6/30/16-6/30/17 Adult Signature Date Signed Medical Insurance Provider Valid For

14 Section 2 Refusal to consent to medical treatment. By signing below, I indicate that the Girl Scouts of Ohio s Heartland Council, Inc. (Girl Scouts), its volunteers, or employees are not authorized to allow the administration of health care to myself in the event of injury or sickness. However, I will not hold the Girls Scouts, its employees, members, or volunteers liable in any way for seeking emergency care (such as calling 911) for my child or providing any health information on this form to emergency personnel. 6/30/16-6/30/17 Adult Signature Date Signed Medical Insurance Provider Valid For MEDICAL HISTORY INFORMATION MUST BE COMPLETED REGARDLESS OF MEDICAL CARE ACCEPTANCE/DENIAL. Health History: Y or N: Explain any Ys Frequent Ear Infections Frequent Headaches Heart Defect/Disease Convulsions Seizures Diabetes Bleeding/Clotting Disorders Hypertension Mononucleosis (in the past year) Musculoskeletal Disorders Allergies Specify Allergen/N Allergy Type Reaction Type and Treatment Animal Hay Fever Poison Ivy Insects Penicillin Medication Food Does child have and know how to use an EpiPen? Health Conditions (Y/N) Bed Wetting Emotional Disturbances Hearing Impairment Dietary Restrictions Fear of Storms Vision Impairment Sleepwalking Asthma Diseases ( Y or N; If Y give dates) Chicken Pox Measles Mumps Hepatitis Immunization (Give last date given) DATE (mm/yy) VACCINE DTaP Tdap Booster Polio MMR Hib Hep B Varicella (pox) TB Test (Indicate +/-) Please provide any information useful to the adult in charge in relation to any of these health conditions. Also, indicate an y activities to be encouraged or restricted by physician or any special dietary needs. (Use Additional Sheet If Necessary) 6/30/16-6/30/17 Adult Sign ature Date Signed Valid Fo r

15 JG Revised 9/12 Global/Public Relations/Photo Release Forms Girl Scouts of Ohio's Heartland 1700 WaterMark Drive Columbus, OH gsoh.org DATES 2016 (8/12, 8/27, 9/9, 9/23, 10/14, 10/26,11/8, 11/11, 12/9, 12/31) 2017 (1/1, 1/13, 1/14, 1/15, 2/10, 2/20, 3/10, 3/12, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 5/12, 5/27, 6/9, 7/4, 7/14) PHOTOGRAPHER/PRODUCER Ptanka Rogers Service Unit 898 ASSIGNMENT Service Unit Events COUNCIL LOCATION ACTIVITY Girl Scouts of Ohio s Heartland Various Various Service Unit Events RELEASE FOR ADULTS For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent and agree to the following: 1. I hereby grant to Girl Scouts of Ohio s Heartland, ( GSOH ), and others working for GSOH or on its behalf, and each of its respective licensees, successors and assigns (each a Releasee ), the irrevocable, royalty-free, perpetual, unlimited right and permission to use, distribute, publish, exhibit, digitize, broadcast, display, modify, create derivative works of, reproduce or otherwise exploit my name, picture, likeness and voice (including any video footage of the same) (collectively, Media ), or to refrain from so doing, anywhere in the world, by any persons or entities deemed appropriate by GSOH, for any purpose (except defamatory) including, without limitation, any use for educational, advertising, non-commercial or commercial purposes in any manner or media whatsoever (whether known or hereafter devised) including, without limitation, on the internet, in print campaigns, in-store and via television. I agree that I have no interest or ownership in any of the Media. 2. I shall have no right of approval, no claim to compensation and no claim (including, without limitation, claims based upon invasion of privacy, defamation or right of publicity) arising out of any use, alteration, blurring, illusionary effect or use in any composite form of my name, picture, likeness and voice. I agree that nothing in this Release will create any obligation on GSOH to make any use of the Media or the rights granted in this Release. I hereby release and hold harmless Releases from any claim for injury, compensation or negligence resulting or arising from any activities authorized by this Release and any use of the Med ia by GSOH. Name of Adult Adult D.O.B. Street Address City, State ZIP Phone (not for release to 3rd parties) Adult Signature Date Signed I, having signed this release, hereby consent to the foregoing conditions and warrant that I have the authority to give such consent. Any revisions to the text of this Release must be approved in writing by GSOH prior to the activity in order for the changes to be effective. PLEASE RETURN COMPLETED AND SIGNED RELEASE TO AUDIO/VIDEO SERVICES, GSOH