Girl Scouts of River Bluffs Council • #4 Ginger Creek Parkway • Glen Carbon, IL 62034
(618) 692-0692 - (800) 345-6858 - FAX (618) 692-0685 • gsrbc@riverbluffs.org
Print page, complete and mail/fax (fax only with credit card info) with fee.
Program Individual Registration Form
(Individual registration can only be used for Girl Scouts 11-17 programs, unless otherwise noted.)
Name of Event _______________________________________________Event #________________________
Date of Event________________________________________Time of Event ___________________________
If choice of sessions, list: 1st _____________ 2nd_____________
Leader/Advisor Name________________________________________________________________________
Troop/Group # _______Service Unit # _______Program Level_______________________________________
Girl Name_________________________________________________________________________________
Address __________________________________________________________________________________
City _____________________________________________ST______Zip Code ________________________
Phone # (Day) _______________________________________(Evening) _____________________________
E-Mail ___________________________________________________________________________________
Additional Information _______________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Program Cost $_________
Payment:
○ Check enclosed: # ___________ Amount $__________○ Mastercard ○ Visa ○ Discover
Card Number ____________________________________________________Expiration Date _____________
Amount $______________Signature ___________________________________________________________
PARENT’S CONSENT
:I request that my daughter/ward __________________________ attend the ____________________________ at ____________________________ and participate in all phases of the activities. I agree to cooperate with all of Girl Scouts of River Bluffs Council regulations. Further, Girl Scouts of River Bluffs Council has my permission to use photographs or videotapes of my daughter/ward for whatever purposes they see fit, including website, with no claim whatsoever on my part.
○ Health history form is attached.
Signature of parent/guardian_______________________________________________ Date_______________
8/29/07