INDIVIDUAL EVENT REGISTRATION FORM

(This form may be copied)

PLEASE PRINT
Name of Event/Training:

COMPLETE ALL SECTIONS

ONE EVENT PER REGISTRATION

Date of Event/Training

Cost: $

per person, amount enclosed $ Full payment must accompany all registrations

VISA/MasterCard/Discover Cardholders Signature Girl/Adult Name Complete Address Email Home Phone ( Troop Leader Troop # Age level: Daisy Brownie Junior )

Expiration Date

Work (

) Service Unit

Cadette

Senior
)

Adult

If parent is not available, second emergency contact (cannot be pager #) Name Phone (

PARENT PERMISSION AND EMERGENCY MEDICAL FORM

I (we) the undersigned parent(s) or legal guardian(s) of , a minor, do hereby request that she be permitted to attend (event) on (date) and should the need arise, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act or a dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his/her best judgement may deem advisable. I do understood that every effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatments will not be withheld if the undersigned cannot be reached. I will not hold liable Girl Scouts of Central California South, its officers, or leaders for medical aid rendered and will reimburse Girl Scouts of Central California South for medical or other expenses incurred in the care of my daughter. This Authorization gives pursuant to Section 25.8 of the Civil Code of California and remains effective only for the event and date listed above. Physician Name City Phone Is she taking medications? No Yes Specify Dosage Date of last Tetanus shot Allergic to Restricted activities/food is I permit photographs of my daughter taken at this event to be used for publicity by authorization of the designated members of the Council. Parent/Guardian Signature_____________________________________ Phone_____________________ Date_____________ Print Name

1377 W. Shaw Ave., Fresno, CA 93711 1831 Brundage Lane, Bakersfield, CA 93304 (800) 490-8653 FAX (559) 291-5079
OFFICE USE ONLY Date received

Initials

Amount received