Troop High Risk Form
For troops or groups planning to participate in activities that require council approval as stated in GSUSA's Safety Activity Checkpoints. This form does not need to be completed for council led activities or activities on council properties. Form must be completed 4 weeks prior to event and proper documentation including: troop roster, all registered adult volunteers and vendor's certificate(s) of insurance must be attached to this form. All incomplete forms may result in delay of approval or denial of event.
Main Contact/Person Completing Form:
First Name
Last Name
Email
[email protected]
Phone Number
Please enter a valid phone number.
GROUP INFORMATION
Type of group:
Troop
Service Unit
Troop number
Service Unit
Please Select
153 Parke/Vermillion County
162 North/South Vigo County
163 Central Vigo County
181 Clay County
183 Putnam County
202 Wayne/Union County
204 Franklin County
205 Fayette County
206 Rush County
316 Grant County
337 Madison County
354 Randolph County
365 Henry County
371 Blackford Coutny
372 Delaware County
382 Jay County
401 Carroll County
407 Howard/Tipton County
520 White County
540 Tippecanoe County
570 Clinton County
580 Montgomery County
590 Benton/Fountain/Warren County
602 Sterling (Boone County)
603 Pike Township
605 Zionsville
607 Danwood (Danville)
608 Westside Indy (Wayne Township)
609 Hunter (Brownsburg)
610 Avon
611 Hamilton Southeastern
612 Morgan County (Martinsville/WaMoNa)
614 Decatur Township
617 Warren Township
625 Irvington/Ft Square
627 SouthEast Indy
628 Shelby County
629 Johnson County South
630 Fishers
635 Midtown
641 Ft Ben (Lawrence Twp)
642 Washington Township
650 East/Central Marion County
651 Manuka (Noblesville Area)
653 JoSheWe (Westfield/Sheridan)
660 Wagon Trail (Plainfield)
663 Carmel East
665 Carmel West
670 Greenwood
671 Hancock County
672 Perry Township
701 Bartholomew County
702 Decatur County
707 Brown County
718 Monroe/Owen County
771 Sullivan County
772 Greene County
774 Switzerland County
775 Ripley County
787 Lawrence County
Unknown
Program grade level(s) of girls participating: Check all that apply.
Number of girls participating
List girls first and last names
List adults first and last names
Number of adults participating
Total number of participants
I confirm that all adults have met Girl Scout requirements to attend this activity
Yes
No
TRIP INFORMATION
Definition of activity types. Select all the apply
Describe High Risk Activity
Activity start date
-
Month
-
Day
Year
Date Picker Icon
Activity end date
-
Month
-
Day
Year
Date Picker Icon
Location/Destination
Address of Location/Destination
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Location Phone Number
Please enter a valid phone number.
Offsite Emergency Contact-Person who can be contacted in an emergency
Phone Number
-
Area Code
Phone Number
Adult Training Certifications/Qualifications
Volunteers participating in activity have the following certifications Check all that apply.
If you noted volunteers with certifications above, please list their names as appropriate below:
Certified Lifeguard Trained adult
Training expiration date
Certified Camp Prep Trained adult
Training expiration date
Certified Archery Trained adult
Training expiration date
Certified Small Craft Trained adult
Training expiration date
Other Certification Trained adult
Other Certification:
Training expiration date
Name of Volunteer with First Aid/CPR certification:
First Name
Last Name
Type of Certification
FA/CPR/AED
Wilderness and Remote
Healthcare Professional
First Aid Expiration
-
Month
-
Day
Year
Date Picker Icon
CPR Expiration
-
Month
-
Day
Year
Date Picker Icon
Submission
Back Up Plan- what alternative plan does the troop have if this trip does not take place?
Submitter Comments/Notes
Submit
Should be Empty: