Training Registration Form

Print out this form, fill out, and mail with fee to:

Program/Training Registrar

Girl Scouts of River Bluffs Council

#4 Ginger Creek Parkway

Glen Carbon, IL 62034

Print one form per training (do not register for multiple courses on one form).

Be sure to include fee, payable to GSRBC.

Registrations that involve a fee may also be faxed to the Program/Training Registrar, only with credit card payment (section at bottom of this form). Fax number is (618) 692-0685.

Course Title:__________________________________________________________ Course Date:_____________________________________

Location of Course:_____________________________________________________________________________________________________

Name:______________________________________________________ Troop #:______________ Service Unit:__________________

Street Address:_____________________________________________ City/State/Zip:_____________________________________________

E-Mail Address:____________________________________________________________

Daytime Phone:________________________________________________ Evening Phone:_______________________________________

Volunteer Position: 1 Leader 1 Co-Leader/Assistant Leader 1 Service Unit Manager 1 TOC 1 Troop Consultant 1 Troop Organizer

1 Other___________________________________________________________________________________________________

Have you attended Introduction to Girl Scouting at River Bluffs 1 Yes 1 NO

Course Fee Enclosed (if applicable): $____________________

Please check any special needs you have (physical, dietary, etc.

1 Speech Impairment 1 Learning Disability 1 Physical 1 Visual Impairment 1 Hearing

1 Other______________________________________________________________________________________________________________________

CREDIT CARD AUTHORIZATION INFORMATION

Credit Card Type: 1 MasterCard 1 Visa 1 Discover

Total amount to be charged $_________________

Credit Card #_____________________________________________ Expiration Date_________

Name on Credit Card_____________________________________________________________

Authorized Signature________________________________________ Date________________