Camper Registration Form
Complete this registration for your camper, including troop details, health information, and required signatures.
Registration
Registration with Girl Scouts MUST be active and updated or camp registration will not be completed.
Scout Level
*
Please Select
Daisy
Brownie
Junior
Cadette
Trailblazer
This group is full. Please join our waitlist here:
https://form.jotform.com/262037449212150
.
Camper First Name
*
Camper Last Name
*
Camper Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Troop/Group Number
*
Parent Email 1
*
example@example.com
Street Address
*
City
*
State
*
Zip Code
*
Parent 1 First Name
*
Parent 1 Last Name
*
Parent 2 First Name
*
Parent 2 Last Name
*
Parent 2 Email
*
example@example.com
Additional Registration Info
Parent 1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent 2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Camper's Preferred Name/Nickname
Age
*
Grade
*
T-Shirt Size
*
Please Select
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Buddy Request
Health Information
Girl Scout First Name
*
Girl Scout Last Name
*
Girl Scout Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Girl Scout Address
*
City
*
State/Province
*
Zip/Postal Code
*
Girl Scout Troop/Group #
*
The above Girl Scout is under the custodial care of:
*
Both Parents
Parent 1 Only
Parent 2 Only
Legal Guardian
Other
Parent 1/Caregiver First Name
*
Parent 1/Caregiver Last Name
*
Parent 1/Caregiver Address
*
City
*
State/Province
*
Zip/Postal Code
*
Parent 1/Caregiver Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent 1/Caregiver Email
*
example@example.com
Parent 2/Caregiver First Name
Parent 2/Caregiver Last Name
Parent 2/Caregiver Address
City
State/Province
Zip/Postal Code
Parent 2/Caregiver Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent 2/Caregiver Email
example@example.com
Emergency Contact 1 First Name
*
Emergency Contact 1 Last Name
*
Relationship to Girl Scout
*
Emergency Contact 1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 First Name
*
Emergency Contact 2 Last Name
*
Relationship to Girl Scout
*
Emergency Contact 2 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physician First Name
*
Physician Last Name
*
Physician Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Dentist First Name
*
Dentist Last Name
*
Dentist Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is the Girl Scout covered by family medical/hospital insurance?
*
Yes
No
Carrier or Plan Name
*
Policy or Group #
*
First Name of Insured
*
Last Name of Insured
*
Relationship to Girl Scout
*
Check all those that apply: medical conditions
*
None of the Above
Asthma
Diabetes
Seizure Disorder
Heart Condition
Allergies
Other
Check those that apply: immunizations
*
Tetanus within past 10 years
Immunization records are up to date
Other
Check those that apply: environmental allergies
*
None of the Above
Pollen
Dust
Mold
Pets
Insect Stings
Other
FOOD ALLERGIES
*
None
Peanuts
Tree Nuts
Milk
Eggs
Soy
Wheat
Fish
Shellfish
Other
By (Typed Name)
*
Parent 1/Caregiver Signature
*
Date of Signature
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Release for Minors
RELEASE FOR MINORS: For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I, the parent or legal guardian of the above-named camper, hereby consent and agree to the following: I hereby grant to Girl Scouts of Greater Atlanta and others working for Girl Scouts of Greater Atlanta or on its behalf, and each of its respective licensees, successors and assigns (each a "releasee"), a one-time use of the photo of my child in association with the article. One time use would be royalty free with unlimited right to distribute and publish and exhibit the photo together with the article. Use of the photo for any other use is not authorized. I shall have no right of approval, no claim to compensation and no claim (including, without limitation, claims based upon invasion of privacy, defamation or right of publicity) arising out of any use, alteration, blurring, illusionary effect or use in any composite form of my child's name, picture, likeness and voice. I agree that nothing in this release will create any obligation on Girl Scouts of Greater Atlanta to make any use of the Media or the rights granted in this release. I hereby release and hold harmless releasees from any claim for injury, compensation or negligence resulting or arising from any activities authorized by this release and any use of the media by Girl Scouts of Greater Atlanta.
I agree
*
I agree
Parent/Guardian Electronic Signature
*
By (Typed Name) :
*
Date of Signature
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Code of Conduct
I agree that I or my child will behave by the Girl Scout Law, be respectful to other campers, leave all alcohol, tobacco, drugs at home. Campers agree to leave electronics put away during camp time.
I agree
*
I agree
Parent/Guardian Electronic Signature
*
By (Typed Name):
*
Date of Signature
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Camp Communication
Email for Camp Communication
*
example@example.com
Additional Email
example@example.com
Camp Registration Refund Policy: On or before March 15, cancellations receive a full refund. Between March 16 and April 15, cancellations receive a 50% refund. After April 15, no refunds will be issued, unless the camper's spot is filled by a same-level replacement camper, in which case a full refund may be issued regardless of date.
I have read and agree to the camp's refund policy: full refund before March 15, 50% refund before April 15, no refund after April 15 (unless the spot is filled by a same-level replacement camper).
*
I agree
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