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Download - Girl Scouts in the Heart of Pennsylvania

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Adventure Bound Registration Form<br />

Please pr<strong>in</strong>t clearly <strong>in</strong> blue or black <strong>in</strong>k. Please fill <strong>in</strong> all <strong>in</strong>formation and mail with a non-refundable $50.00 deposit per<br />

adventure bound week to: GSHPA, Attn: Registrar, 350 Hale Avenue, Harrisburg, PA 17104<br />

Contact Information<br />

Camper’s Name______________________________________________________Troop______________________<br />

Parent 1____________________________________Parent 2____________________________________________<br />

Address_______________________________________________________________________________________<br />

City________________________________________State__________________ZipCode_____________________<br />

Daytime Phone______________________________ Even<strong>in</strong>g Phone______________________________________<br />

Email:________________________________________________________________________________________<br />

Emergency Contact Name________________________________________________________________________<br />

Address_____________________________________City_________________________State_________________<br />

Daytime Phone______________________________ Even<strong>in</strong>g Phone______________________________________<br />

Camper DOB (M/D/YR)__________________Camper Grade__________ Camper Age________________________<br />

Fall <strong>of</strong> 2012 <strong>Girl</strong> Scout Level<br />

Senior: 9 th Grade 10 th Grade Ambassador: 11 th Grade 12 th Grade<br />

Allergies:___________________________________Dietary Restrictions________________________________<br />

Ethnic Orig<strong>in</strong>: American Indian/Alaskan Native Asian/Pacific Black White Hispanic<br />

Adventure Bound Programs<br />

These programs have a very limited capacity. Please select below <strong>in</strong> numerical order which program she would like<br />

to attend and provide a second choice should <strong>the</strong> first one be closed, if applicable. If <strong>in</strong>terested <strong>in</strong> multiple<br />

programs, place a check mark (‘√’) <strong>in</strong> <strong>the</strong> space provided.<br />

Furnace Hills<br />

Camp Archbald<br />

___ Boat Bike and Backpack- $695 ___ River Rats- $750<br />

___ Climb and Canoe- $650 ____ Adventure Pack- $795<br />

- Check this box if you are register<strong>in</strong>g for multiple programs, please place a ‘√’ by each program<br />

Please Choose One:<br />

Camper is a registered <strong>Girl</strong> Scout with GSHPA<br />

Camper is a registered <strong>Girl</strong> Scout outside <strong>of</strong> GSHPA (additional $12 fee is <strong>in</strong>cluded)<br />

If so, Troop #_____________________Council Name________________________________<br />

Camper is NOT a registered <strong>Girl</strong> Scout with<strong>in</strong> GSHPA (additional $12 fee is <strong>in</strong>cluded*)<br />

*This registrant has my permission to jo<strong>in</strong> <strong>Girl</strong> <strong>Scouts</strong>.<br />

Payment Information on back<br />

2012 Summer Camp - Adventure Bound Registration Form Rev. 12/11<br />

17

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