ConnectZ Registration Form

ConnectZ Registration Form
Girl Scouts River Valleys ConnectZ is a staff led program that provides Black, Indigenous, People of Color (BIPOC) youth, and those in underserved communities, an opportunity to be a part of diverse Girl Scout troops at no cost to them or their families. Complete this registration form to get started or to renew your membership as a ConnectZ Girl Scout.
Girl Information
New member (first time registering)Re-registering
If you are re-registering, how many years have you been a Girl Scout?*
Girl Name*

First NameMiddle NameLast Name
Mailing Address (Zip Code Required)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Girl Cell Phone Number (Optional)
Format: (000) 000-0000.
Birthday*

MonthDayYear
Date
Grade
School*
Student I.D.
School issued student ID
Girl's Email (If different from parent/guardian)*
example@example.com
Girl's Cell Phone
Format: (000) 000-0000.
Parent/Guardian Information
Ms.Mrs.MissMr.Other
Parent/Guardian Name*

First NameLast Name
Mailing Address (If different from girl's address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number (Optional)
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Membership Data

By completing the following optional questions, you can help ensure community support and funding for Girl Scouts. Girl Scouts respects and welcomes people from all backgrounds and abilities. Thank you for providing the information requested. Sharing this information is optional and is used for statistical purposes only.
AfricanAmerican Indian or Alaskan NativeAsianBlack or African AmericanHawaiian or Pacific IslanderWhiteI choose not to shareOther
YesNoI choose not to share
Language spoken at home (Optional)
DevelopmentalHearingLearningPhysicalVisualI choose not to shareOther
If you need special accommodations please contact Girl Scouts River Valleys at 800-845-0787.
YesNoI choose not to share
Health Information
YesNo
ADHD (Attention Deficit and Hyperactivity Disorder)AsthmaDiabetesHeadachesSeizuresAlergiesOther
Please specify girl allergies in the text box below.
Emergency Contact Name (Other than parent/legal guardian)

First NameLast Name
Emergency Contact Primary Phone Number (Other than parent/legal guardian)
Format: (000) 000-0000.
Acknowledgments
Yes, I agree.
Yes, I agree.
Yes, I understand.
Yes, I agree.
Yes, I agree.
Yes, I agree.
Yes, I agree.
Yes, I agree.
Yes, I agree.
Signature of Parent/Legal Guardian: *

Limpiar
Signature of Girl (Optional)

Limpiar
Date

MonthDayYear
Date
Should be Empty:

ConnectZ Registration Form

Girl Information

Parent/Guardian Information

Membership Data

Health Information

Acknowledgments