Additional Insurance Request
All registered Girl Scout members are covered by Plan 1 insurance, paid by their membership fees; this plan covers approved daytime activities or overnight activities lasting up to two nights. For all other activities, participants must be covered by additional insurance. Additional insurance is required for Non-members and tagalongs who participate in Girl Scout Activities, any age Girl Scout for whom the event is not planned and is not a worker/helper Girl Scouts taking extended trips of longer than three days and two nights, all foreign travel.
Purchaser's Name:
*
First Name
Last Name
Enter Troop Number or Staff
*
Purchaser's Email
*
example@example.com
Purchaser's Phone Number:
*
Please enter a valid phone number.
Event Start Date:
*
.
Month
.
Day
Year
Event End Date:
*
.
Month
.
Day
Year
Event Name or Description:
*
Event Location:
*
Event Activities:
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*What will you be doing?
Program Grade Level(s):
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Daisy
Brownie
Junior
Cadette
Senior
Ambassador
Adult
Tagalongs
How many registered girls are attending?
*
How many registered adults are attending?
*
How many non-registered adults are attending?
*
*This includes boys 13 years old or older.
How many Tagalongs are attending?
*
*Girls under 5 and boys under 13 are considered tagalongs - DO NOT include adults.
How many boys under the age of 12 are attending?
*
Total number of participants are attending?
*
Please Choose One:
*
Please Select
Troop/SU Event
GSSA Staff/Council Program
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Payment Information
We will run your card for the amount of insurance required for your event. The average cost is $.29 per person attending your event. There is a minimum purchase amount of $5. You will receive an email with the amount and a copy of the receipt.
Credit Card Number
*
Expiration Date:
*
CCV (3-digit code on back of card)
*
Billing Zip Code
*
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All Done! Click the Submit button to send your request for Additional Insurance to Customer Care.
Submit
Date Purchased
Date Run Through Shop
Amount Run Through Shop
Should be Empty: