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 #/Group Name *

Service Unit # *

County *

Grade Level *

Daisy Brownie Junior Cadette Senior Ambassador

Type of Trip *

High Risk Activity (i.e. whitewater rafting, horseback riding and 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 is a trip over 48 hours (click here if you have an Extended Trip of over 48 hours)(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 *

example@example.com

Activity Description *

Estimated Mileage (Round Trip) *

Destination name, address, and phone number *

Departure date and time *

Month Day Year

at

Hour Minutes AM/PM Option Date Picker Icon

Return date and time *

Month Day Year

at

Hour Minutes AM/PM Option Date Picker Icon

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 Date Picker Icon

Troop and Group Activity Application