CLE Annual Permission Form

1
Permission Forms (Volunteer Policies, page 25) The Annual Permission Form allows for troop trips/activities that are

located within one hour’s driving time of the regular meeting place

not exceeding 6 hours

not considered high risk activities

as outlined in Safety Activity Checkpoints (ex: high ropes, zip line, equestrian). Trips/activities outside of these parameters require a separate Single Activity Permission Form. Activity Consent, Hold Harmless and Release Agreements may be required, depending on the activity.
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Select your troop location* This field is required.
Please Select
Please Select
Fairfax Recreation Center
Earle B. Turner Recreation Center
*Stephanie Tubbs Jones Health Center
UH Community Wellness Center at Glenville (pending)
Mary B. Martin School (pending)
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5 Digit Troop NumberContact your troop/group leader if unknown
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Name of Girl Scout* This field is required.
First Name
Last Name
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Girl Demographics* This field is required.
Grade (if summer, please share grade entering)
School
Full Name of Parent/Caregiver
Current Age
Relationship to child
Please enter your email
Mobile Phone
Home Phone
7
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Emergency Contacts* This field is required.Please enter two & be sure to notify them they are emergency contacts for your child.
Emergency Contact #1
EC #1 Phone
EC #1 Relationship to child
Emergency Contact #2
EC #2 Phone
EC #2 Relationship to child
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Permission for Trips (1)* This field is required.My daughter/dependent has permission to travel to, attend, and participate in troop activities that are 1) located within one hour's driving time of the regular meeting place, 2) not exceeding 6 hours and 3) not considered high risk activities outlined in Safety Activity Checkpoints (ex: high ropes, zip line, equestrian). Troop/group leader must provide written details prior to each trip. Trips outside of these parameters require a separate permission form.
YESNO
10
Permission for Trips (2)* This field is required.My daughter/dependent has permission to travel to, attend, and participate in troop activities that are 1) located within one hour's driving time of the regular meeting place, 2) not exceeding 6 hours and 3) not considered high risk activities outlined in Safety Activity Checkpoints (ex: high ropes, zip line, equestrian). Troop/group leader must provide written details prior to each trip. Trips outside of these parameters require a separate permission form.
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Permission to Participate in Product Sales (1)* This field is required.My daughter/dependent has permission to participate in the Fall Magazine & Snack Program and the Cookie Program. I agree to accept financial responsibility for all orders and movies for which my Girl Scout is accountable and will observe and adhere to all procedures and deadlines imposed. I understand that product may not be returned and that all money earned is the property of Girls Scouts of North East Ohio and not to be retained by any one individual. I understand that Girl Scouts reserves the right to take appropriate action to secure payments for products received by me. I further understand that she must have adult guidance at all times when participating in the Product Sale and she must not take product orders before the official start of the product sale program as determined by Girl Scouts of North East Ohio.
YESNO
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Permission to Participate in Product Sales (2)* This field is required.My daughter/dependent has permission to participate in the Fall Magazine & Snack Program and the Cookie Program. I agree to accept financial responsibility for all orders and movies for which my Girl Scout is accountable and will observe and adhere to all procedures and deadlines imposed. I understand that product may not be returned and that all money earned is the property of Girls Scouts of North East Ohio and not to be retained by any one individual. I understand that Girl Scouts reserves the right to take appropriate action to secure payments for products received by me. I further understand that she must have adult guidance at all times when participating in the Product Sale and she must not take product orders before the official start of the product sale program as determined by Girl Scouts of North East Ohio.
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Product Sales Financial Responsibility I agree to accept financial responsibility for all orders and movies for which my Girl Scout is accountable and will observe and adhere to all procedures and deadlines imposed, if applicable.
Driver's License Number
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Permission to Use Photographs (1)* This field is required.I consent that photographs, videos, and/or audio recordings of my daughter/dependent may be used by the troop/group leader for public relations and publicity purposes, including GSNEO publications, social media, and various forms of media. While GSNEO typically does not use girls' last names, I understand that her last name may be used by the media for publicity purposes.
YESNO
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Permission to Use Photographs (1)* This field is required.I consent that photographs, videos, and/or audio recordings of my daughter/dependent may be used by the troop/group leader for public relations and publicity purposes, including GSNEO publications, social media, and various forms of media. While GSNEO typically does not use girls' last names, I understand that her last name may be used by the media for publicity purposes.
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Permission for Emergency Medical Treatment* This field is required.In the event of an emergency, every effort will be made to contact a parent/caregiver or emergency contact. If no contact can be made, I hereby give authorization to Girl Scouts of North East Ohio to seek treatment for my child and/or dependent minor by a licensed physician. I know of no reason(s) why my daughter/dependent may not participate in prescribed activities except as noted on the Personal Health and Medical Record Form.
YESNO
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NOTE: If permission for emergency medical treatment is not given, please prepare a signed statement providing the reason, a release of liability, and alternate instructions and submit to your troop/group leader to be included with this form.
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Permission for Emergency Medical Treatment* This field is required.In the event of an emergency, every effort will be made to contact a parent/caregiver or emergency contact. If no contact can be made, I hereby give authorization to Girl Scouts of North East Ohio to seek treatment for my child and/or dependent minor by a licensed physician. I know of no reason(s) why my daughter/dependent may not participate in prescribed activities except as noted on the Personal Health and Medical Record Form.
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Special Accommodations: My daughter/dependent requires the following special accommodations (type "none" if there are none):
Huge
Large
Normal
Small
Ok
Ok
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COVID-19* This field is required.I understand that COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. As with any social activity, participation in Girl Scouts could present the risk of contracting COVID-19. While GSNEO encourages our volunteers to take every safety and preventative precaution, GSNEO can in no way guarantee that COVID-19 infection will not occur through participation in Girl Scouts.
YESNO
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COVID-19* This field is required.I understand that COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. As with any social activity, participation in Girl Scouts could present the risk of contracting COVID-19. While GSNEO encourages our volunteers to take every safety and preventative precaution, GSNEO can in no way guarantee that COVID-19 infection will not occur through participation in Girl Scouts.
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Parent/Caregiver Agreement:* This field is required.I have read and understand this Annual Permission Form. I may change or revoke any aspect of this agreement at any time by submitting my request, in writing to the troop/group leader. If I decline to complete this form, I agree to provide the troop leader with individual permission forms for all trips and product sales.
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