This is the 2009 event registration form. You can use this for the NASA rocket event in September.

1. Girl Scouts of Louisiana - Pines to the Gulf
Program/Event Registration Form
Please Print & Include Registration Fee
Return to any service center to the ATTN: Program Department.
Registration is for: Troop/Group Adult
* Non-registered Girl Scout * Individual Girl - not registering with a troop
(*complete individual girl information below)
Event Code (mandatory):__________ Event Name______________________________________________ Event Date_______________
Program Age Level (please check): Daisy Brownie Junior Cadette Senior Ambassador Juliette
Service Unit #_______________ Troop #_________________ Parish______________________________________________________
___________________________________________________________ Email_______________________________________________
Troop Leader’s Name (please print clearly)
Address_________________________________________________ City___________________________________ Zip_____________
Phone # (H) (______) __________________ (W) (_______) _______________________ (C) (_______) ____________________________
Cost per girl $______ Cost per adult $_______ AI/AN A B/AA H/PI H/O W TOTAL
Total Amount Enclosed $_________________
# Girls
Payment in FULL is required for form to be processed.
Send payment amount for only event listed on form
# Adults
Payment Information (please check):
Check (Payable to Girl Scouts of Louisiana - Pines to the Gulf)
Key: AI/AN – American Indian/Alaskan Native A – Asian
MC VISA Discover Cookie Dough
B/AA - Black or African American H/PI – Hawaiian/Pacific Islander
Name on Card_________________________________________
H/O – Hispanic, Other W - White
Account # _____/ ______/_______/________ Exp. Date_____/____
Cardholder Signature________________________________________________
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THE FOLLOWING MUST BE COMPLETED AND SIGNED BY A PARENT/GUARDIAN FOR ANY GIRL
REQUESTING TO ATTEND AN EVENT OR ACTIVITY AS AN INDIVIDUAL.
***For girls attending with a troop/group – troop adults are responsible for obtaining parent permission and health information for
participating members unless requested otherwise in the event details. Please list full names of girls and adults attending the event on the
back of this form.
List any health conditions that event coordinator should be aware of or would limit girl’s participation in activities:
__________________________________________________________________________________________________________________
List current medications:______________________________________________________________________________________________
Allergies to medication, food, insects, etc.________________________________________________________________________________
Physician or Clinic:______________________________________________________Phone (_____)________________________________
Person to notify in case of emergency, if parents cannot be reached:
Name_________________________________________________________________Phone (_____)________________________________
Address_____________________________________________City____________________________State____________Zip____________
I give permission for my daughter to participate in the activity listed at the top of this event form, including transportation, if provided, to and
from the program sites.
I hereby give Girl Scouts of Louisiana – Pines to the Gulf the right and permission, without compensation to use photographs/videos of my
daughter and her name for publicity and public relations purposes. I give permission for my daughter,________________________,to
receive emergency medical treatment if necessary.
__________________________________________________ _________________________________________
Signature of Parent/Guardian Date