Private Residence Annual Authorization Form

Girl Scouts of Connecticut does not recommend meeting in private homes.

All adults age 18 and older who reside in the home will be required to complete a background check. The location will not be approved until the background checks are completed.

If you will be meeting in a private residence on a regular basis, the homeowner/renter must submit this form at least two weeks prior to the first meeting in the home.

Please make sure that all areas of the private residence selected for troop/group meetings and/or activities are easily accessible to all members, including girls with different abilities.

Please review the Meeting Place Safety Guidelines found here.

This form must be completed annually.

You will receive a confirmation once your request has been approved.

Troop/Group Number *

Level (select all that apply) *

Daisy (Grades K-1) Brownie (Grades 2-3) Junior (Grades 4-5) Cadette (Grades 6-8) Senior (Grades 9-10) Ambassador (Grades 11-12)

Service Unit Name *

Troop/Group Co-Leader *

First Name Last Name

Troop/Group Co-Leader

First Name Last Name

Troop/Group Co-Leader

First Name Last Name

Number of Registered Girls in Troop/Group *

Number of Registered Adults in Troop/Group *

Name of Homeowner/Renter *

First Name Last Name

Address of Home *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Phone *

Area Code Phone Number

Cell Phone *

Area Code Phone Number

Email *

example@example.com

Adults 18 and over Residing in the Home (n/a if none) *

Legal First Name

Legal Last Name

Date of Birth

Email

Adult 1

Adult 2

Adult 3

Adult 4

Adult 5

Types of All Pets in the Home (n/a if none) *

Type

Pet 1

Pet 2

Pet 3

Pet 4

Pet 5

As the Homeowner/Renter, please read and check each of the following requirements *

As the homeowner/renter, I have adequate insurance on the property and accept the potential liabilities of having Girl Scout activities at our residence.

Please note: In the event of an accident, your homeowners insurance will be accessed.

Signature

Clear

Name *

First Name Last Name

Email *

example@example.com

Today's Date *

Date