Girl Scouts of North East Ohio
Resident Camp/One Day Girl Program Registration
IMPORTANT GSNEO GSNEO GSNEO GSNEO
Central/North South East West
One form per camper, per
One Girl Scout Way 1010 Applegrove St NW 980 Warren Ave
session Complete both Macedonia, OH 44056-2156 N. Canton, OH 44720 Niles, OH 44446
6111 S. Broadway Ave
sides of this form Lorain, OH 44053
330-864-9933 330-433-9485 330-652-5876 440-233-6112
Required deposit for each 330-467-1901 fax 330-499-4475 fax 330-544-7959 fax 440-233-7393 fax
program must accompany
registration Completed forms may be walked in to any service center, mailed to the Macedonia office or
faxed to (330)467-1901. Incomplete forms will be returned
Camper Information - ONLY ONE CAMPER PER FORM
Camper Name __________________________________________ Camper Birthdate ____________ Grade in fall ________
City/State/Zip ______________________________________________________________ County _____________________
Troop Number _______________ (if applicable)
Age Level in the Fall: Daisy Brownie Junior Cadette Senior Ambassador
Are you currently a registered Girl Scout? Yes No Years of Resident Camp ___________
Parent/Guardian Contact Information
Parent/Guardian Name ___________________________________________ Relationship to Camper ___________________
Address (if different from above) ____________________________________________________________________________
Phone (home) ____________________ Phone (work) _____________________ Phone (cell) _________________________
Email _______________________________________ How would you like to receive confirmations? Email Postal Mail
Camper is in the custody of: Both Parents Mother Only Father Only Other (explain) ___________________
Resident Camp Registration - ONLY ONE CAMP SESSION PER FORM
Indicate Session Choices:
Program Name Camp Location Program Code Date Fee
1st _____________________ _______________________ ____________ ____________ ______________
2nd _____________________ _______________________ ____________ ____________ ______________
3rd _____________________ _______________________ ____________ ____________ ______________
One Buddy per Form - your buddy must have your name listed on their form.
Buddy's Name _____________________________________________
If a camper is coming with a buddy, list the buddy's name. Buddy must be the same program age level.
Girl Scouts of North East Ohio
Resident Camp/One Day Girl Program Registration (page 2)
Camper Name _________________________________________ Camper Birthdate __________________________
Fees and Payment Method
Deposit Fee $ ____________ $50 deposit or payment in full
Financial Aid Deposit $ ____________ 10% of highest program fee or $5 for individual girl programs
Pathway Passes $ ____________ Include pathway passes
Girl Scout Membership (if applicable) $ ____________ If not currently a Girl Scout, include $12 registration fee
Total Payment Enclosed $ ____________ Cash Check Money Order Credit Card
If paying by credit card please complete the Credit Card Payment Authorization Form.
Your total balance due will be included in your confirmation information.
I give permission for my camper to become a member of GSUSA for the 2010 year (ending September 30, 2010), attend
Camp Ledgewood/Sugarbush/Timberlane/Great Trail Resident Camp and participate in all activities unless otherwise
indicated on her health form.
I have attached a completed Camp Financial Assistance Application to this registration and included my 10% deposit.
The financial assistance deadline is May 15, 2010.
Parent/Guardian Consent - SIGNATURE REQUIRED TO PROCESS *Final consent/release will be
provided with confirmation
I agree that my child may be transported for program or emergency purposes in a vehicle designated by the Camp Director.
I understand that the Girl Scouts of North East Ohio is not responsible for the personal property of any camper.
I understand that there are inherent risks in program activities, and my camper agrees to cooperate and follow the program and
safety rules of the camp staff.
I agree that the Camp Director has the authority to discontinue participation in the program if my camper does not follow the
program safety instructions and policies, and/or endangers others due to her behavior.
I authorize the Girl Scouts of North East Ohio and the Girl Scouts of the USA to use photographs, videotape, and/or audio
recordings of my daughter for the purpose of promoting Girl Scouting.
Enclosed is the required deposit and I agree to pay the balance at least 2 weeks before the camp session begins.
I understand that on camp arrival day, the camp medical personnel have the right to refuse to admit a girl to the camp who does not
meet the acceptable health conditions regarding temperature, contagious disease, lice, etc.
I authorize the director to obtain medical care for my camper in case of emergency.
Parent/Guardian Signature ________________________________________________ Date __________________
Print Name ________________________________________
For Office Use Only
Date Received Amount Received Program Code Balance Due Confirmation Date
____________ _____________ ___________ _________ ______________