Summer Camp Permission Slip Form - Girl Scouts Of The Missouri Heartland - 2016
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1For Online Registration 2016
Girl Information
Name __________________________________________ 5-Digit Troop Number ________________
Address __________________________________ City _______________ State _____ Zip ________
□
□
Registered Girl Scout for 2014-2015?
2015-2016?
Yes
No Birthdate _________ Grade in Fall 2015 ______
2016
Parent/Guardian Information
Name _____________________________________________________________________________
Address __________________________________ City _______________ State _____ Zip ________
Home Phone (___)____________ Cell Phone ( __)_____________ Work Phone (___)_____________
E-Mail ____________________________________________________________________________
Emergency Contact Information (person to be notified in case a parent/guardian cannot be reached)
Name ________________________________________ Relationship to Camper _________________
Home Phone (___)_____________ Cell Phone (___)____________ Work Phone (___)____________
Camp and Program Session Information
Registration
Camp Location
Program
Date
Parent/Guardian Permission
I, the undersigned parent/legal guardian of _____________________________ (“child”), authorize the child’s
participation in Girl Scout Summer Camp (“the program”) and all related activities, including horseback riding,
archery, ropes, and water sports. I have read the camp information and I understand it and agree to cooperate
with all the regulations. The camp staff has permission to seek medical attention for the child in the event of an
accident or sickness, to administer any prescription drug sent to camp with the child or any medication prescribed
in the event of an accident or illness, and to administer any non-allergic over-the-counter medicines as needed
(such as Tylenol). I give permission for out-of-camp travel which is part of the program. Girl Scouts of the Missouri
Heartland has permission to use pictures, slides, and/or audio-video tapes of the child taken while she is involved
in activities for council publicity and public relations purposes. I feel the child is prepared for camp, and
understand that, if possible, homesick children will not be sent home, but will be closely observed and helped to
overcome the separation anxiety they are experiencing.
I recognize and acknowledge that there are certain risks of physical injury to the child in the program. I,
the child, and my insurer, hereby release, waive, relinquish, and discharge Girl Scouts of the Missouri
Heartland, Inc. and any and all directors, officers, employees, agents, and/or volunteers from any and all
claims, demands, action, or causes of action whatsoever, arising out of or related to any loss, damage, or
injury, including death, that may be sustained by the child as a result of the child’s participation in the
program, whether caused by negligence (including, but not limited to, negligence by any person acting on
behalf of the Girl Scouts of the Missouri Heartland, Inc., negligent training, or negligent supervision) or
otherwise. I further acknowledge that I understand that this is a full release and that I have voluntarily
waived my rights and those of the child and insurer.
Parent/Guardian Name ______________________ Signature ________________________ Date ____________
P:\GSMOHEARTLAND DATA\Forms\Resident Camp 2-20-2014
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