10.07.2015 Views

GO! Great - Girl Scout Council - Colonial Coast

GO! Great - Girl Scout Council - Colonial Coast

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ACTIVITY REGISTRATION FORM FOR ONE INDIVIDUAL GIRL OR ONE TROOPRegister online at gsccc.org OR mail this form with total payment to: <strong>Girl</strong> <strong>Scout</strong> <strong>Council</strong> of <strong>Colonial</strong> <strong>Coast</strong> l 912 Cedar Road l Chesapeake, VA 23322Deliver this form in person to: A Place For <strong>Girl</strong>sl 912 Cedar Road l Chesapeake, VA 23322Peninsula Service Center, 813 Forrest Dr., Suite B, Newport News, VA 23606Elizabeth City Field Center, 214 N. Dyer St., Elizabeth City, NC 27909Fax this form to: (757) 547-1872Individual Participant’s Name (for individual registration) ________________________________________________________________________SU# ____________________Troop # ________Age ________ _________ Circle Level: DS BR JR CD SR ABStreet Address __________________________________________ City ______________________________ State __________ Zip __________Phone ________________________________________ Email address _______________________________________________________Name of troop leader/adviser _________________________________________________________________ SU# ________ Troop # _________________# Of <strong>Girl</strong>s Per Level: DS# ________ BR# _________ JR# _________ CD# _________ SR# _________ AB# ___________Street Address __________ City ______________________________ State _______________________________________ Zip ____________Phone____________________________________________________ Email address ___________________________________________1. Activity Name ______________________________________ Date ___________ Time ____________________________Fee $ __________Other information ______________________________________________________________________________________________________2. Activity Name ______________________________________ Date ___________ Time____________________________Fee $ __________Other information _____________________________________________________________________________________________________Enclose full payment with this form. Enclose half (maximum $5) of the fee per girl, per activity with any <strong>Girl</strong> Opportunity Fund ApplicationPlease list the name of each girl in your troop/group who will be attending the activity:1. _____________________________________ 5. _____________________________________ 9. ____________________________________2. _____________________________________ 6. _____________________________________ 10. ____________________________________3 _____________________________________ 7 _____________________________________ 11 _____________________________________4 ____________________________________ 8 ____________________________________ 12_____________________________________Office Use Only: RC# ____________________ Date ____________ Date confirmation sent : ____________Do you need special accommodations? q Yes q No If yes, please attach note to describe.Complete and bring <strong>Girl</strong>s Health History Form to the activity. Copies of these forms can be found on our Web Site at gsccc.org.only need to be completed onceper troop year.You have my permission to use my daughter’s voice or photo to tell the public about the <strong>Girl</strong> <strong>Scout</strong> Program. q YesParticipant has my permission to participate in activity listed above and will not attend if ill.q NoI agree that my account will be debited electronically for the face amount, return check fee and return deposit item fee if returned unpaid.Parent/Guardian/Leader Signature ______________________________________________________________ Date________________________Payment receipt for office use only:Date received for office use only:DEPOSIT # ________________ DATE ___________Check written by:RECEIPT # _________________________________CASH $ ______ CHECK $ ______ CHARGE $_____PAYMENT METHOD: q Cash q Check q Money Order Amount enclosed: $_____________ Make check payable to GSCCCPlease charge to my: q VISA q MasterCard q Discover Amount to be charged: $_______________Account #:________________ -- _______________ -- ______________ -- _____________Expiration Date:____________ (Mo/Yr)Print name as it appears on card: ________________________________ Authorized Signature:_____________________________________26

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