Camper Registration

CAMPER REGISTRATION

AREA 9 & 12 DAY CAMP

8:30AM-4:30PM

JUNE 22-26, 2026
- Full Payment is due at the time of registration!
  - Exception 1: JSLF Scholarship - A minimum deposit of 10% of the total due must be submitted at the time of registration if you have applied for a JSLF Scholarship.
  - Exception 2: Troop Payments - Do not pay anything at the time of registration if the troop is paying full camp fee.
  - The date of registration will be used as the "Paid in Full" date for these exceptions.
- Be prepared to provide health information (insurance, immunization/tetanus, history, medications, etc.)
- Register one camper at a time.
- Do not use this form for Adult Volunteers or Camp Aides.
- This form must be completed by a legal parent/guardian.
INDEX
Family Email Verification - THIS EMAIL ADDRESS IS HOW WE WILL COMMUNICATE WITH YOU (look for email from noreply@jotform.com)*

Camper Information
First Name (legal)*
Camper Legal First Name
Preferred Name*
The name camper goes by - this name will be on her nametag and paperwork.
Last Name*
Camper surname/last name
Sex (legal)*
Preferred Pronouns*
Birth Date*

MonthDayYear
T-shirt Size*
Troop Number*
Enter 000 for Juliettes/independent.
Girl Scout Area*

912Other
Camper Address*

Street Address

Street Address Line 2

CityState

Zip Code
List all siblings attending camp:*
Enter N/A if no siblings are attending.
Do you want to request placement with a buddy?*

NoYes
Buddy First and Last Name*
One name only. Do not enter troop numbers or schools. Buddy requests must be reciprocal and placements are not guaranteed.

Parent/Guardian Information
Camper is in the custody of:*
Relationship to camper:
Mother/Guardian Name

First NameLast Name
Cell Phone Number
Email
Father/Guardian Name

First NameLast Name
Cell Phone Number
Email
Emergency Contact (not a parent/guardian)*

First NameLast NameRelationship to Camper
Cell Phone Number*
Other Phone Number
Approved Pick-Ups*
Enter the name(s) of any person who has permission to pick-up your camper. Include parents/guardians.

Policies and Permissions
Health Information Privacy Statement From GSUSA

The health history form is for health care concerns at this camp only. All medical records will be held in limited access by the health care supervisor of this camp. Minimally necessary information may be shared with the camp staff / volunteers in order to provide adequate participant safety and health care. The health history form will be retained by GSK along with all forms / records with noted treatment for 7 years past the age of maturity of the participant. Access to the information will be limited. I have read the above procedures for handling health history information and I agree to the release of any records necessary for treatment, referral, billing or insurance purposes.
PHOTO RELEASE AGREEMENT

Throughout the week, we take photographs and video of the campers to share with camper families. Attendees will receive a link to a private photo album to view photos/videos from that year. We also use a few images and videos on our Facebook account and website. In addition, the council occasionally requests photos from camp to use in promotional materials. Being mindful of the safety of all the children and the privacy of all individuals who participate, we would like to obtain your permission to upload images and videos that may contain your child. Images and videos may be used in the following ways:
1. Private Photo Album - Area 9 and 12 Google Album 2026 (only viewable by attendees.
  1. If you select "NO" then camper will be removed from the group for group photos and similar.
2. Area 9 and 12 Day Camp Media and Promotion (Website, Social Media, print materials)
3. Girl Scouts of Kentuckiana Council Media and Promotion
PHOTO PERMISSION - Private Photo Album:*

Yes, I want to see photos and videos of my camper and hereby grant permission for my camper to appear in the Private Photo Album.No, Do not take photos or videos of my camper (camper will be removed from the group for group photos and similar)
PHOTO PERMISSION - Area 9 and 12 Day Camp Media and Promotion*

Yes, I hereby grant permission for my camper to appear in Area 9 and 12 Day Camp Media and Promotional materials.No
PHOTO PERMISSION - Girl Scouts of Kentuckiana Council Media and Promotion*

Yes, I hereby grant permission for my camper to appear in Girl Scouts of Kentuckiana Council Media and Promotional materials.No

Fee and Payment Summary
Volunteer Information and Discount - Does this camper have an adult volunteer working at camp?*

Yes, Working 5+ DaysYes, Working 1-4 DaysNo
Volunteer Name*
Volunteer Discount Agreement*

I understand that the credit card on file will be charged $50 if the volunteer fails to fulfill their commitment of 5 full days at camp.
Camper Fee
Overnight Fee
Bus Transportation
Volunteer Discount
Total Due
10% Total Due
Signature of Parent/Guardian: In the above permission statements, my "child" and/or "camper" refers to: {firstName} {lastName}*

Clear
Date

MonthDayYear
Date
Should be Empty: