Girl Scout Spring Break Camp Form

Girl Scouts of Western Ohio
I can’t wait to ...
Make new friends
Go on an environmental
adventure
Create new memories
Discover my own natural treasures
Be a Girl Scout at Spring
Break Day Camp!
Are you ready to have the best spring break ever with Girl Scouts?
We have put together a Fun-cyclopedia of all things exciting. Come explore with us—we
will help you discover how you can have fun and make new friends all while learning about
loving our planet. Join us at Girl Scouts Spring Break Day Camp today!
Who:
Girls in kindergarten through sixth grades looking to have the best Spring Break ever
(For girls currently not registered in Girl Scouts.)
When:
Monday through Friday, March 30 through April 3, 2015, during your daughter’s
school spring break.
Time:
Choose from one half day session: 9 a.m.–12 p.m. or 1–4 p.m.
Where:
Mt. Auburn Presbyterian Church, 103 William Howard Taft Road, Clifton, OH 45219
Cost:
$15 per girl for half-day session (Financial assistance available to all girls.)
Return the attached registration form along with your payment to your school’s office
by Friday, March 20, 2015.
Financial assistance is available on the attached registration form.
Questions? Please contact Cheryl Shrider at 513-619-1424 or cherylshrider@gswo.org.
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Dear Parents/Guardians:
Welcome to Girl Scouts. In Girl Scouting, girls discover, connect and
take action. We strive to help girls understand themselves and their
values, use their knowledge and skills to explore the world, care about,
inspire and team with others locally and globally, and act to make their
world a better place.
The great news is that Girl Scouts is coming to your neighborhood.
Girl Scouts of Western Ohio is sponsoring a Spring Break Day Camp at
Mt. Auburn Presbyterian Church, 103 William Howard Taft Road, Clifton,
OH 45219. Girls will learn Girl Scout traditions, participate in many
hands on and team building activities, play games, learn songs and
come home each day with wonderful new memories!
All girls from kindergarten through third grades, who are not current Girl
Scouts are welcome to attend.
How do I register?
To register for the Girl Scouts Spring Break Day Camp, please complete the attached registration
form and return it to your child’s school office. There is a $15 registration fee, which covers the cost
of all the days of camp, as well as Girl Scouts registration. Financial assistance is available upon
request.
Will there be transportation?
Unfortunately, transportation will not be provided. You will indicate on the confirmation packet
who will be allowed to drop your Girl Scout off and pick your Girl Scout up.
Who is facilitating the sessions?
The sessions will be facilitated by a combination of Girl Scouts staff and volunteers. All of our staff
and volunteers have completed an application, background check and are trained.
Will the girls be with girls from different grade levels?
While all girls in kindergarten through sixth grade will attend Spring Break Day Camp, the girls will be
broken out by grade level once they arrive at the camp for most of their activities.
Can adults be involved in Girl Scouts?
Of course! Parent(s)/guardian(s) are welcome to volunteer for a day or
the whole week of Spring Break Day Camp. If you would like to help,
please indicate the times you would like to volunteer in the space
provided on the attached registration form. A staff member will contact
you before camp begins to discuss the process to become a volunteer;
such as online application, background check and becoming a registered
member of Girl Scouts and submit the $15 annual registration fee along
with your specific volunteer days, times and roles.
We hope to see you and your daughter at our Girl Scouts Spring Break Day
Camp! If you have any questions, please feel free to contact me at
513-619-1424 or cherylshrider@gswo.org.
Sincerely,
Cheryl Shrider
Recruitment Manager
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Girl Scouts of Western Ohio
Spring Break Day Camp
First Name:
Address:
Phone:
Last Name:
City: Cincinnati
Email:
For office use only
486 49891
New
State: OH
Zip:
Check here if you don’t have an email address
I wish to opt in:
School:
Racial Background:
Re-reg
Grade:
American Indian or Alaskan Native
Hawaiian or Pacific Islander
Ethnic Background:
Hispanic or Latina
Parent/Guardian Name:
Emergency Contact Name:
Text
email
Birth Date:
Asian
White
Black or African American
Other
Not Hispanic or Latina
Alternate Phone:
Phone:
Yes, I would like to volunteer to be
A leader
An assistant leader
a troop/group helper
Cash
Check enclosed (payable to Girl Scouts of Western Ohio) or charge my credit card:
Visa/MasterCard/Discover
Am Express
Card Number:
Exp. Date:
CVV (3-digit):
Signature on Card:
Billing Zip Code
Financial Assistance
FINANCIAL ASSISTANCE FOR MEMBERSHIP FEE
Financial assistance may be available for girls who want to attend but are unable to do so
because of limited family income. Applicants are encouraged to pay some portion of the fee.
Please complete the line below. All fees are non-refundable.
Family can pay $
Total $15
Financial assistance requested $
I understand the nature of the activities in which my child is going to participate and give my permission
for my child to: 1) engage in all program activities as planned by the Girl Scouts of Western Ohio and its
affiliates, 2) for the Girl Scouts and or its affiliates to use her picture (s) or video recording(s) and 3) if my
daughter is not a registered Girl Scout I am willing to have my daughter become a registered Girl Scout
member.
Parent/Guardian Signature:
Date:
PARENT/GUARDIAN PERMISSION AND HEALTH HISTORY
List any medical conditions requiring treatment, medication, or special needs:
Allergies this person has:
Special needs this person has:
Name of Family Physician:
Phone Number:
This health history is correct to the best of my knowledge, and the person herein described has
permission to engage in all prescribed event activities except as noted.
Authorization for Treatment: In the event that I cannot be reached in an emergency, I hereby grant
permission to the physician selected by the event personnel to secure treatment, including
hospitalization, for the patient.
Signature of Parent/Guardian:
Turn over to complete
Date:
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Girl Scouts of Western Ohio
Camp Session
Please choose one half day session:
9 a.m.–12 p.m.
or
1–4 p.m.
DROP OFF/PICK UP INFORMATION
Please PRINT and use the full name of the adult as it appears on their identification.
Please limit to two people other than parents/guardians.
Camper’s Name:
The persons listed below have permission to pick up the above camper from the camp at:
Mt. Auburn Presbyterian Church at 103 William Taft Road, Clifton, OH 45219.
Please ensure this person brings ID when picking up your camper.
(Name) Mother/Guardian
(Name) Father/Guardian
(Name)
(Relationship to camper)
(Name)
(Relationship to camper)
PARENT/GUARDIAN PARTICIPATION
If you are interested in volunteering, please indicate the days on which you would like to volunteer below.
A staff member will then contact you regarding volunteering.
To volunteer at Spring Break Day Camp, the following steps will need to be taken two weeks prior to the start of
camp.
1. Online application
2. Online background check
3. Online register as an adult member of the Girl Scout organization. Adult membership annual fee is $15 and to be
paid online. Paper registration forms available upon request.
Monday
Tuesday
Wednesday
Thursday
Friday
9 a.m.–12 p.m.
9 a.m.–12 p.m.
9 a.m.–12 p.m.
9 a.m.–12 p.m.
9 a.m.–12 p.m.
1–4 p.m.
1–4 p.m.
1–4 p.m.
1–4 p.m.
1–4 p.m.
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