Holly Pines Online Registartion Documents

Camper Information
Campers Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Returning Camper*

YesNo
Age*
Birth Date*

MonthDayYear
Date
Troop Number (0 if no troop)*
School*
Current Grade (2025-2026 school year)*
Parent email for all camp correspondence.*
example@example.com
Age Level*
Camper Shirt Size*
Transportation-bus times and stop won't be available until May*

We need a busWe will drive our camper
Picture of Camper File Upload*

Cancelof
Unit Buddy (We can guarantee one buddy)
*Buddy needs to be the same Girl Scout level.
I give Holly Pines Day Camp my consent that any photographs, film, audio, or visual for which she posed may be used by HPDC or Girl Scouts of Southeastern, Pa.*

Contract of Behavior
All Parents, Staff and Campers are required to read and sign the Contract of Behavior to complete their registration.

Strike 1: Camper/Staff is sent to the Camp Director for a conversation with another adult present about the undesired behavior. An email will be sent to the parent/guardian.

Strike 2: Same as Strike 1 and the camper will be given a chore to do for camp depending on the age of the camper (ie: sweep HQ, wash dishes from camp cooking A call will be placed to the parent/guardian.

Strike 3: Same as Strike 1. A call will be placed to the parent/guardian to pick up the Camper/Staff and they will be asked not to return to HPDC. No refund will be issued.

What counts as a strike?
- Any behavior that puts anyone at camp in danger.
- Talking back or disrespecting staff af ter three warnings.
- Wandering away or not staying with your assigned unit of ter three warnings.
- Not following directions after three warnings.
There are adult volunteers at camp to comply with Girl Scout ratio, if an adult is disrespected by a camper or camp staff it is an automatic strike.
I, First Name* have read the above contract and understand that to keep everyone safe and having fun I must follow the rules and directions given by the HPDC staff. If I do not follow the rules and directions, I understand the consequences.
Camper/Staff signature: Signature*
I,   First Name*      have read the above contract and understand that to keep everyone safe and having fun my camper must follow the rules and directions given by HPDC staff. I understand that if I am called to pick up my Camper/Staff, I must pick them up or make arrangements for them to be picked up in a timely manner. I also understand that I will not get a refund if my daughter is asked to not come back to HPDC due to behavior.
Parent/Guardian signature:   Signature*

Emergency Information

In the event of an emergency, we always attempt to contact a parent/guardian FIRST. If they are unavailable, please list those who can be called to collect a sick child or authorize medication. Please note that it is our policy to ask for photo ID before releasing a child.
Camper's Name*

First NameLast Name
Mother/Guardian #1: First and Last Name*
Primary Phone: Phone Number* Secondary phone: Phone Number*
I'd like to volunteer at camp
Father/Guardian #2: First and Last Name*
Primary Phone: Phone Number* Secondary phone: Phone Number*
I'd like to volunteer at camp
Emergency Contact #1: Name Relationship: *
Primary Phone: Phone Number* Secondary phone: Phone Number*
Emergency Contact #2: First Name* Relationship: Type a label*
Primary Phone: Phone Number* Secondary phone: Phone Number*
Emergency Contact #3: First Name Relationship:
Primary Phone: Phone Number Secondary phone: Phone Number
Name of Physician:   First Name*      Phone:      Phone Number*
Family Hospital:   *
Insurance Carrier:   Type a label*   Policy/Group #:   Name*

GSEP High Risk Form for Activities at Holly Pines Day Camp

High risk activities are these that demand greater physical ability, emotional stamina, and skill. These activities may require specialized training, equipment, and supervision. Please see the Safety Activity Checkpoints and Girl Scouts of Eastern Pennsylvania High Risk Activity List for requirements when participating in a high risk activity. When participating in any high risk activity, all registered Girl Scouts must have a signed High Risk Activity Permission Form and a current Health History Form. This form may be used instead of a Parent Permission for Troop Activity form when applicable.

Troop #: Holly Pines Day Camp Adult in charge: Nikki Massey

Cell #: 215-834-5602 Start Date July 13, 2026 End Date: July 24, 2026
Boating and Fishing- All ages, Lifeguard on duty

Clear
Slingshot- 2nd grade and up only, taught by trained adult

Clear
Bouldering- 2nd grade and up only, taught by trained adult

Clear
Archery- 2nd grade and up only, taught by trained adult

Clear
BB Guns- 4th grade and up only, taught by trained adult

Clear
I understand HPDC is not responsible for loss of valuables.*
Full payment is due at the time of registration and I understand my camper is not registered until payment is completed in full.*
Venmo: @Nikki-Massey-2 (5602) Checks can be sent to HPDC, 59 W Chestnut St, Souderton.
I verify that all information I provided is correct to the best of my knowledge and belief. I also understand that there are no refunds for Holly Pines Day Camp for any reason.
First Name* Date* Signature*
Should be Empty:

Camper Information

Contract of Behavior

Emergency Information

Health History Information and Medication Consent: