Download - Girl Scouts in the Heart of Pennsylvania

Payment Information
Adventure Bound
Boat Bike and Backpack ($695)
Climb and Canoe ($650)
River Rats ($750)
Adventure Pack ($795)
Camp Deposit per camp session ___________X $50
Non Girl Scout Fee ($12)
Out of Council Girl Scout Fee ($12)
Total
=$____________
=/+$____________
=/+$____________
=/+$____________
=/+ $____________
+ $____________
+ $____________
= $____________
Total
Early Bird Registration: April 15, 2012 ($15)
Campership Amount Requested
Product Sales Dough (must send in card)
Donation/Sponsor another Camper
Total Enclosed
= $____________
-$____________
-$____________
-$____________
+$____________
=$____________
Payment Type
Check Check #: Amount Enclosed:
Credit Card Visa Mastercard Discover
Account #:
Expiration Date:
CCV (Code on back):
Amount to be charged:
Money Order Money Order #: Amount Enclosed:
My child has permission to attend Girl Scouts in the Heart of Pennsylvania’s adventure program and
participate in all phases of activities both on and off camp property, including transportation out of
camp, except as noted on the health form. When participating in any activity, she may be photographed
for print, video or electronic imaging. We agree the images may be used in promotional materials, news
releases and other published formats for either the local Girl Scout Council or Girl Scouts of the USA. I
have read the camp guide and agree to cooperate with all regulations. I agree not to hold the Council or
its representatives responsible in cases of illness, accident or loss.
I have read and understand the registration information. The information above is correct and complete
to the best of my knowledge.
_____________________________________________________________________________________
Signature
Date
_____________________________________________________________________________________
Print
Date
2012 Summer Camp - Adventure Bound Registration Form Rev. 12/11
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