Camper Registration Form

Custodial Information
While the camper is at camp, they are in custodial care of?*

Mother/Guardian OnlyFather/Guardian OnlyBoth Parents
Mother/Guardian Name*

First NameLast Name
Father/Guardian Name*

First NameLast Name
Custodial Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Custodial Phone Number*
Please enter a valid phone number.
Indicate phone type*

HomeWorkMobile
Custodial Email Address*
example@example.com

Contact Information

A local alternate contact must be supplied (for emergency use only). No parent/guardian to be used.
Emergency Contact*

First NameLast Name
Relationship to Camper *
Phone Number*
Please enter a valid phone number.
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The following Checked boxes are authorized to pick up my child from camp*

Parent(s)/Guardian indicated onlyParent(s)/Gaurdian indicated and emergency contactMy daughter will be in a carpool and a list will be suppliedI will give you a list of Authorized People
Buddy Request - you may request one person to be in the same unit at camp.

First NameLast Name
If your camper is a part of a carpool and/or there is a list of authorized people, please list them here.

Signatures
If I am exposed to contagious disease in the three weeks prior to event/program, I will notify the director.

Clear
To the best of my knowledge, this health history is correct.

Clear
In case of emergency, I give my permission to persons representing Girl Scouts of Colorado to see that I receive appropriate emergency medical or surgical treatment, and/or hospitalizaition if necessary. It is understood that every effort will be made to reach teh person named above as my emergency contact.

Clear
Date
Photo Release
I, Being the Parent/Guardian of Camper's Name hereby consent that her name, image, and likeness, as shown in the video-tapes, photographs, motion picture film and/or electronic images for which she posed, and/or audio recordings made of her voice may be used by Girl Scouts of the U.S.A., its assigns or successors, in whatever way they desire, including television and Web sites; furthermore, I hereby consent that such photographs, films, recordings, electronic images, and the plates, tapes and/or software from which they are made shall be their sole property, and they shall have the right to sell,duplicate, reproduce and make other uses of such photographs, films, recordings, electronicimages, plates, tapes and software as they may desire free and clear of any claim whatsoever on my part.
Signature

Clear
Name of Camper
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
I, being of legal age, hereby consent, that my name, image, and likeness, as shown in the videotapes, photographs, motion picture film and/or electronic images in which I appear,and/or audio recording made of my voice may be used by Girl Scouts of the U.S.A., its assignsor successors, in whatever way they desire, including television and Web sites; furthermore, I hereby consent that such photographs, films, recordings, and electronic images and the plates, tapes and/or software from which they are made shall be their sole property, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs,films, recordings, electronic images, plates, tapes and software as they may desire free and clear of any claim whatsoever on my part

Clear
Date Signed
Should be Empty:

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H2O Sports Sampler Registration

Camper's Information

Custodial Information

Contact Information

Health History

Immunization History

Signatures

Photo Release