Troop/Group Activity Application

Submit this application at least two weeks prior to any activity which involves an overnight stay, a high-risk activity, or travel of more than 200 miles round trip from your normal meeting place.

Note: This application is not required for overnight stays at NYPENN Outdoor Adventure Centers. For trips over 48 hours, please use the Extended Trip Application. A copy of the approved application will be forwarded to your Service Unit Manager.

Troop/Group Information

Troop # *

Service Unit # *

County *

Grade Level *

Daisy Brownie Junior Cadette Senior Ambassador

Type of Trip *

High Risk activity (eg. whitewater rafting, horseback riding, ropes course) Day Trip (first aider required) Indoor/Lodging Camping or Overnight (first aider and SSO required) Outdoor/Tent Camping (first aider and SSC required) Extended Trip (over 48 hours) Use Extended Trip Application (http://www.gsnypenn.org/content/dam/girlscouts-gsnypenn/documents/extended-travel.pdf)

Leader's name *

First Name Last Name

Leader's mailing address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Leader's phone # (day) *

- Area Code Phone Number

Leader's phone # (evening) *

- Area Code Phone Number

Leader's email address *

Activity Description *

Estimated Mileage (Round Trip) *

Destination name, address, and phone number *

Departure date and time *

- Month - Day Year

at

: Hour Minutes

Return date and time *

- Month - Day Year

at

: Hour Minutes

How is this trip being funded?

How is girl and adult planning incorporated? What steps have been taken to ensure troop readiness?

Required Adult Trainings

Name of First Aid and CPR Chaperone *

Fiirst Name Last Name

First Aid Chaperone phone # *

- Area Code Phone Number

Type of First Aid and CPR certification *

We accept American Red Cross, National Safety Council, EMP of America, American Heart Association trainings

First Aid expires

MM/DD/YR

CPR expires

MM/DD/YR

For Indoor Lodging Camping or Overnight

Name of SSO Trained Chaperone (may not be first aider):

First Name Last Name

Phone Number

- Area Code Phone Number

SSO Course Location:

SSO Course Date:

MM/DD/YR

For Outdoor/Tent Camping

Name of SSC Trained Chaperone (may not be first aider):

First Name Last Name

Phone Number

- Area Code Phone Number

SSC Course Location:

SSC Course Date:

MM/DD/YR

Emergency Contact

Does your location have cell service to call 911? *

Yes No

If not, name local fire and rescue numbers that you will use in an emergency.

Emergency on-site phone/cell number (A leader or approved adult on location at the trip.)

Emergency off-site phone/cell number (The person who is available by phone during the trip and has a list of names, addresses, and phone numbers of those attending. This contact is not on the trip; it is someone local.)

Transportation

Vans with a seating capacity of more than 10 passengers are prohibited. Please assure that all drivers are approved volunteers (background checked) and have a current driver's license and car insurance. *

Individual Public Leased/Rented Vehicle (requires council approval and signatures on contracts) Leader/Adult vehicle Chartered bus (requires council approval and signatures on contracts)

Safety Checkpoints

First Aid Kit Health History Forms Updated Parent Permission Slips Lifeguard Boating/Small Craft Certified Chaperone Reviewed Safety Activity Checkpoints (http://www.gsnypenn.org/en/for-volunteers/safety-activity-checkpoints.html) Additional insurance is required for non-registered adults or tagalongs? (If yes, contact Customer Care at 800-943-4414.)

List the Safety Activity Checkpoints that were reviewed

Located on line at http://www.gsnypenn.org/en/for-volunteers/safety-activity-checkpoints.html

Participant Names

Girls *

Adults* *

*For the safety of all girls, all adults going on your trip must be registered and have a current background check on file with GSNPENN.

Please contact Customer Care at 1-800-943-4414 with questions.

Certification

I hereby certify that the above information is correct. I have reviewed safety standards and will be responsible to see that all participating girls and adults meet the requirements.

Type leader's digital signature *

Date *

- Month - Day Year