SUBMIT AGREEMENT PAYMENT CAMP DETAILS MEMBERSHIP PARTICIPANT INFO INSTRUCTIONS Be sure to read event registration details before registering. Please print clearly with blue/black ink or type. Forms cannot be transferred from one event to the next. Incomplete registration forms will not be processed. Full payment must accompany registration form unless deposit option listed in event details. Deposits are non-refundable unless camp is cancelled due to low registration. Pre-registration is necessary to ensure adequate materials are available. No walk-ins will be accepted. No refunds will be given after the close of registration. First Middle Last Summer Camp Registration Form For Council Day Camp, Weekend Camp, Resident Camp and Travel Camp P:304.345.7722 F: 304.345.6427 www.bdgsc.org Grade School Date of Birth (MM/DD/YYYY) Girl Scout Level Parent/Guardian Email I wish to opt in: Yes, I will help Council use resources wisely and receive my confirmation via e-mail. Apartment City State Zip Code ( ) ( ) ( ) Day Phone Evening Phone Cell Phone ( ) Emergency Contact (other than parent/guardian) Emergency Contact Phone (REQUIRED) Accomodations needed (accessibility, medical, dietary, etc). Name of adult attending camp with girls (Camp director will contact you about this request.) Is the adult attending a Registered Girl Scout? Yes No Has the attending adult completed a Volunteer Application & Background Check? Yes No I am currently a member of GSBDC Troop# I am an IGirl/independent Girl Scout I am currently a member of another council (name) Troop# I would like to join as an individual member of Girl Scouts with this registration and have included $15 for GSUSA membership dues. Cash Check Make checks payable to Girl Scouts of Black Diamond Credit Card VISA, MasterCard, Discover, AmEx Gift Card I have read the program details and give my child permission to participate in the activity listed above. I understand that I am responsible for arranging transportation to and from event location, unless a transportation option is listed in event details. If transportation is part of the camp program, I give permission for my daughter to be transported to the activity. I understand that in case of emergency, every effort will be made to contact a parent/guardian prior to medical treatment. If the parent/guardian cannot be reached, however, and the situation requires immediate emergency attention as determined by the Girl Scout representatives, I hereby authorize representative of Girl scouts of Black Diamond Council to obtain necessary treatment for my daughter. If my daughter is not currently a Girl Scout, I authorize Girl Scouts of Black Diamon d to register her for the current membership year. Yes No I give permission for photographs, videos, audio recording, and quotations of my child taken by authorized Girl Scouts of Black Diamond Council staff or their designee to be used for council publications, television, or the World Wide Web. Yes No Signature of Parent/Guardian FAX 304-345-6427 Must pay with Credit Card GSBDC cannot confirm receipt of FAX Do not mail original form once fax is sent Name on Credit Card: Credit Card/Gift Card #: Expiration Date(MM/YY): Signature: Your signature above signifies your agreement to allow Girl Scouts of Black Diamond Council to charge the above amount to your credit card. You agree to pay this amount pursuant to the agreement you have with your credit card provider. MAIL Girl Scouts of Black Diamond Council PO Box 507 Charleston, WV 25322 Registration for all events will close on date listed in event details, or sooner if event fills before registration deadline. One registration form must be completed for each girl attending. Only girls currently in grade listed in event details may attend event. Girls must be a registered Girl Scout. For overnight events, adults must be a registered Girl Scout and complete the volunteer application process. Attach a girl health history form and Medication & First Aid Products Permission for each girl attending day or weekend camp. Resident & Travel Camps rquire a Health Exam due at the start of camp. Camp Name Location Date(s) Fee(s) Deposit(s) I will be paying the entire amount due, for all camps. I would like to opt into the payment plan. I will pay the deposit due now and pay the remainder by the registration deadline (3 weeks before camp). Date Total Fees & Deposits Deposits are non-refundable. Membership Fee $15.00 REMINDERS Consider using priority mail to ensure timely receipt. Allow up to 10 days for delivery recommended.
Girl Opportunity Fund Application for Programs P:304.345.7722 F: 304.345.6427 www.bdgsc.org APPLICANT INFORMATION ELIGIBILITY/INSTRUCTIONS Based on need, Girl Scouts of Black Diamond Council will offer funds to girls who request financial assistance. Eligibility Girls must be a registered Girl Scout. Applicant would be unable to participate in the activity unless Applicants may be eligible for Girl Program Opportunity Fund up to twice a year, if the second experience is significantly different from the first. If applicants is requesting Girl Program Opportunity Funds for an council event, applicant must have participated in at least one product sale. Applicant can t owe debt to GSBDC. Instructions Be sure to read event registration details before registering. Please print clearly with blue/black ink or type. Forms cannot be transferred from one event to the next. Incomplete registration forms will not be processed. This application must be completed by the parent or guardian of girl. Forms will not be accepted, if completed by troop leader or another person. Please mail Girl Program Opportunity Fund Application with an Event Registration. The Girl Program Opportunity Application does not register an applicant for Membership, Event, or Camp. Girl Program Opportunity for council event, and Day Camp must be received two weeks before registration date. Girl Program Opportunity for Destinations must be received three months before final payment to GSUSA. A letter will be emailed or mailed notifying the applicant of the decision and the final amount must be sent by the registration deadline for council events, travel, local area event, and Destination deadline. One Girl Program Opportunity Fund Application must completed for each request for each person. GSBDC does not provide assistance to the entire troop. GSBDC does not provide assistance for troop trips. GSBGC makes every effort to provide financial support, so that no girl is denied participation in a Girl Scout experience due to lack of funds; however, Opportunity Funds are limited. The request is for: Council Events Camp Local Area Event GSUSA Destinations Is the applicant a registered Girl Scout member? Yes No Local Area: Is the applicant a: Daisy Brownie Junior Cadette Senior Ambassador Adult Applicant s Name: First Last Troop # Apartment City State Zip Code County ( ) ( ) Phone Cell Phone E-Mail Parent/Guardian Name Mother s Employer Father s Employer I wish to opt in: Yes, I will help GSBDC use resources wisely and receive my communications via e-mail rather than mail. Household Income: $10,000 or less $10,000 - $20,000 $20,000 - $40,000 $40,000 - $60,000 $60,000 - $80,000 $80,000 or more Number in household: Explain reason for request, including any extenuating circumstances or support comments: Occupation Occupation
AGREEMENT EVENT DETAILS EVENT DETAILS Please tell us about the event you would like to attend: Name of Event Event Date(s) Is this a council program? Yes No Event Location Event Code Did applicant participate in the Cookie Sale? Yes No Did applicant participate in the Fall Product Sale? Yes No Cost of Event: Family Pay: Troop Pay: Amount Requested: If this is not a council program, please provide details on where to send a check. Checks must go to the event chair or registrar. Make check payable to Name of person to mail check to Volunteer Position City State Zip Code County ( ) Phone E-Mail In utilizing this form, you are agreeing to comply with all Girl and Adult procedures, and certify the applicant above is a registered member of Girl Scouts of the USA. You also agree that you are the Parent or Guardian of applicant or you are the applicant. Signature of Parent/Guardian Date SUBMIT FAX 304-345-6427 GSBDC cannot confirm receipt of FAX Do not mail original form once fax is sent MAIL Girl Scouts of Black Diamond Council PO Box 507 Charleston, WV 25322 REMINDERS Consider using priority mail to ensure timely receipt. Allow up to 10 days for delivery recommended. OFFICE USE ONLY Date: Amount Approved: Account #: Approved: Reviewed by: