RESIDENT CAMP REGISTRATION FORM

VISIT WWW.GSOH.ORG FOR REGISTRATION INFORMATION. PRINT NEATLY OR TYPE. USE BLUE OR BLACK INK.

CAMPING

I wish to share a tent/cabin with (list only ONE person)____________________________

Are special accommodations needed? (Sign interpreter, brailled materials, etc.):

_________________________________________________________________________

Girl’s name__________________________________________________ Age________________

Street address__________________________________________________________________

City____________________________________________State_________ZIP_______________

Home phone ( ) _________________________________

Parent/Guardian daytime#____________________________Cell phone:__________________

Parent/Guardian daytime#___________________________Cell phone:___________________

Parent email address: ____________________________________________________________

Grade completed by summer____________________ Birthday ________/________/________

Please check if: Non-Ohio’s Heartland Girl Scout ____________________________________

(at time of camp)

Dates

Name of program

Riding bus ($40)?

1ST CHOICE

IF CUSTODIAL PARENTS CANNOT BE REACHED, PERSON TO BE NOTIFIED IN CASE OF EMERGENCY:

Name ________________________________________________________

Street address _________________________________________________

Daytime phone ( ) __________________________________________

Home phone ( ) ____________________________________________

Cell phone ( ) ______________________________________________

If custodial parents will be out of town during camp, where can you be reached?

Address ______________________________________________________

City ________________________ State________ ZIP ________________

Phone ( ) _________________________________________________

Expiration date Signature of card holder (required for credit card payments) Date

Billing address City State ZIP

Amount Account number (typically 16 digits)

MAKE CHECKS PAYABLE TO: Girl Scouts of Ohio’s Heartland Council, Inc. OR complete below if you wish to chage your deposit to Visa, MasterCard, Discover or American Express (deposit and bus fee are non-refundable).

VISA MASTERCARD DISCOVER AMERICAN EXPRESS

$

Make check FOR deposit (AND $40 BUS FEE IF APPLICABLE) payable and remit to:

Girl Scouts of Ohio’s Heartland Council, Inc.1700 WaterMark Drive, Columbus, OH 43215

Date received

Financial assistance

Deposit

Program fee Balance due

Confirmation sent

Balance paid

Late fee

Horse Yes No

Bus Yes No

OFFICE-USE-ONLY

Resident Camp Deposit 40.00 = $ _____________

Bus fee 40.00 = $ _____________

TOTAL INCLUDED = $ _____________

(council where registered)

R E G I S T R AT I O N

Yes No Yes No

2ND CHOICE

If yes, check bus stop: Columbus Delaware

SESSIONS

T-SHIRT SIZEAny registration recieved before ApriL 1stincludes a free T-shirt.

Youth YS YM YL

Adult AS AM AL AXL

Fax: 614-487-8189

Questions? Call 614-487-8101 or email corahelp@gsoh.org