Download - Girl Scouts in the Heart of Pennsylvania
Download - Girl Scouts in the Heart of Pennsylvania
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 />
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