[WIP] Program Pack Registration Form

Finalize Text/Instructions here. May not be needed, but need to consider all ways people will be accessing this page. e.g. If they get here directly from a flyer for instance is the language on that flyer sufficient to just lead with the banner above and get straight to the form?

[PH] Complete the form below and submit payment to register your girl for the GSHNC Program Pack!
Caregiver Information
Caregiver Name*

First NameLast Name
Email Address*

Confirmation Emailyouraddress@service.com
Phone Number*
Please enter a valid phone number.
Phone Type*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver Birth Date*

MonthDayYear
Date
Caregiver Gender*
Caregiver Relationship to Girl*
Check if you were a Girl Scout. Daisy, Brownie or higher-it all counts.
Girl Information
Girl Name*

First NameLast Name
Girl lives at same address as the Caregiver.
Girl Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Grade*
If today is BEFORE August 1, enter the grade they are completing. If today is August 1 or after, enter the grade they will be going into.
School Attending*
Girl Birth Date*

MonthDayYear
Girl Email
Girls over 13 may provide an email address to also receive emails from GSUSA and GSHNC.
Girl Phone Number
Girls over 13 may provide a phone number to also receive texts from GSUSA and GSHNC.
Phone Type
Age
Demographic Information

Girl Scouts respects and welcomes people from all backgrounds and abilities. By completing the following information (as defined by the U.S. Census Bureau), you ensure support and funding for girls in your community. Hispanic/Latina is defined as an ethnicity, not a race, therefore is reported separately. This information is used for statistical purposes only.
Girl Ethnicity
Girl Race
Caregiver Ethnicity
Caregiver Race
Order Information
[Emily] Need a customer facing summary of Program Pack details here once they are finalized, reiterate what they are buying, cost and what it includes, etc.
Review the GSUSA privacy policy*

I agree with the GSUSA Privacy Policy
Review the Terms and Conditions*

I agree with the Terms and Conditions
Review the Girl Scout Child Abuse Prevention policies and procedures.*

I affirm that I understand and agree to adhere to Girl Scout Child Abuse Prevention policies and procedures.
I agree to the GSUSA Photo Policy (Optional)Email opt in - I agree to receive emails from GSUSA (Optional)SMS opt in - I agree to receive text messages from GSHNC standard data and text messaging rates apply (Optional)
[PH] Paypal/Stripe checkout mockup below, just an image for now so follow through from the form can be tested without payments.

[Jon] Make final connection to paypal once full process is defined and tested.
Order Date

MonthDayYear
Date
Payment Amount
USD
Form is protected by automated reCAPTCHA*
Should be Empty:

Caregiver Information

Girl Information

Demographic Information

Order Information