2026 SMILE Camp Counselor Application & Health Form

Please Note: You must be registered Girl Scout in order to participate in SMILE Camp as a Camp Counselor

All applications must be submitted by Saturday, June 10th, (with one adult reference form). Examples of adults to give reference form: teacher, spiritual leaders, family friends, no relatives please. Counselor spots are filled on a first come, first served basis.

Dates: June 13-19

Location: North Florida School of Special Education
223 Mill Creek Rd, Jacksonville, FL

Application Fee: $150

If you have any questions, don't hesitate to text or email Sherri "Bubba" Johnson
Email: gsbubba1964@gmail.com
Phone: (904) 710-2106

Girl's Name*

First NameLast Name

Girl's Preferred Name/Nickname

Girl's Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Girl's Home Phone Number*

Area CodePhone Number

Girl Email*

Girl Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

YesNo

Troop #*

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Email*

Emergency Contact Name (Someone other than the Parent/Guardian)*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Person authorized to pick up my child after event (if other than Parent/Guardian)

First NameLast Name

Girl's Date of Birth*

MonthDayYear

Girl's Age*

Girl's Current Grade (2025-26 School Year)*

Girl's Health History (Check all that apply)*

If Other Please Specify

Girl's Allergies (Check all that apply)*

Girl's Allergic Descriptions/Reactions

Girl's Additional Health Information (Check all that apply)*

If you checked any of the above please explain

Permission to take or use the following (Check all that apply)*

List all current medications currently being taken. Please include dosage and any potential harmful interactions

Special Dietary Needs*

By signing below I agree that the health history is complete and accurate. My daughter has permission to engage in all activities, except as noted. I will not allow her to attend if she is not in good physical condition. A health examination within the preceding 12 months is required for participation*

Parent/Guardian Signature

I, the undersigned parent or legal guardian of child named above, a minor, do hereby authorize and consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment rendered by a licensed physician or under the general or special supervision of any member of the medical staff and emergency room staff or a duly licensed hospital in the United States and Canada. I further authorize a Girl Scouts of Gateway Council representative to select a medical doctor and/or hospital of his/her best judgment, may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the above named minor, but that any of the above treatment will not be withheld if the undersigned is not reasonably available to give consent. *

Parent/Guardian Signature

YesNo

If so, how many years?

Who was your camper last year?

Have you had any experience working with children? With children with special needs?*

Why do you want to attend Smile Camp?*

Why do you feel you are qualified to work at Smile Camp?*

Describe what you think working with a special needs child would be like.*

I understand that I am signing up for 1 week of Smile Camp, June 2026, during which I will be working as a counselor for a child who is disabled. I understand that the goal of Smile Camp is to offer each and every camper a week of camp, during which they participate in all activities to their ability, experience a week of fun and gain new skills. I agree to do my best to ensure that my camper participates in all activities and has a wonderful time at camp. I understand that SMILE Camp is a program offered by the Girl Scouts of Gateway Council as a way for teens to further their personal development, gain leadership skills and offer services. I understand that I am expected to live by the Girl Scout Promise and Law.

Girl Scout Promise: On my honor, I will try: To serve God and my country, to help people at all times and to live by the Girl Scout Law.

Girl Scout Law: I will do my best to be: honest and fair, friendly and helpful, considerate and caring, courageous and strong, and responsible for what I say and do. And to respect myself and others, respect authority, use resources wisely, make the world a better place and be a sister to every Girl Scout .I agree by signing below to live by the Girl Scout Promise and Law.

My behavior will at all times reflect this agreement.

I understand that if I do not live by the Promise and Law — and my behavior is not a reflection of the Promise and Law — I may be asked to leave Smile Camp.

Applicant's Signature

Girl's Signature

Today's Date*

MonthDayYear

By signing below I consent to allow all pictures taken of my child to be used for publicity purposes by the Girl Scouts of Gateway Council, Inc. I hereby indemnify and hold the above organization, its directors, officers and staff harmless against any and all claims of damages arising out of the taking or use of any pictures or names of myself or my minor child/children*

Parent/Guardian Signature

As the parent/guardian of above named camper, I also understand the Counselor Agreement and its terms.*

Parent/Guardian Signature

Today's Date*

MonthDayYear

SMILE Counselor Application Fee

$150.00 Quantity

Total

$0.00

Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info

2026 SMILE Camp Counselor Application & Health Form

Contact Information

Health Information

Smile Camp Information