Just for Seniors

Senior Girl Scout Conference

June 24-27, 2004

ADULT Registration Form

Please PRINT clearly.

Name

Troop #

Council

Years in Girl Scouting

Address

Fax Number

City, State ZIP

Email Address

Telephone #

What's your Shoe Size?

(Please circle)

Small

(5-6)

Medium (7-8)

Large

(9-10)

(10-13)

Fax or email will be used to send you confirmation of your registration.

Travel Information

I will be arriving in Kansas City by (please check one): ( ) car; ( ) train; ( ) plane; ( ) bus.

I'll be arriving on (Date) ____/____/04 at (Time)

I'll be leaving on (Date) ____/____/04 at (Time)

Cost

Conference Fee (includes conference materials, 7 meals, excursion transportation, overnight accommodations for 3 nights)

$150.00

Conference Souvenirs - Must be ordered by April 15, 2004.

a) Just for Seniors Patch

Quantity

$1.50

Each

b) Just for Seniors Pillowcase

Quantity

$6.00

Each

c) Just for Seniors T-Shirt

Small

Medium

Large

(Please indicate quantity & size)

Quantity

$9.00

Each

d) Just for Seniors Drawstring Backpak

(check your color choices)

Orange

Purple

Lime Green

Sky Blue

Lemon Yellow

Fuchsia

Outside Backpak Color

Inside Backpak Color

$10.00

Each

Excursion Selection – You may choose between our all-day excursions or two half-day excursions. These must be reserved and paid for at the time of registration and prior to April 15, 2004.

¨ Full-Day Excursions – If you select an all-day excursion, please choose one of the following. Costs for these excursions must be paid for at the time of registration and prior to April 15, 2004. Lunch is at your own expense on the site of your excursion.

A-1 Oceans of Fun

$17.00

A-2 Worlds of Fun

$17.00

A-3 Canoeing Trip

$10.00

A-4 Kansas City Quilt Hop

$10.00

¨ Half-Day Excursions – If you select two half-day excursions, please number your excursion choices for morning and afternoon in order of preference for each time block. Every effort will be made to give you your first choice. Costs associated with these excursions, if any, will be paid at the time you enter the attraction. Join us at Loose Park for lunch.

Morning Half-Day Excursions

Choice #

Afternoon Half-Day Excursions

Choice #

B-1 Kansas City Speedway

C-1 AMC 20 Movie

B-2 Kansas City Zoo

C-2 Country Club Plaza

B-3 Liberty Memorial

C-3 Crown Center

B-4 Nelson Art Gallery

C-4 Oak Park Mall

B-5 Steamboat Arabia

C-5 Pepsi Ice

B-6 Toy & Miniature Museum

C-6 Union Station

B-7 Truman Library/House

C-7 Westport

¨ Lunch in the Park – Please select your lunch preference if you participate in half-day excursions.

Hot dog, chips, drink

$3.50

Kansas City Burger or Kansas City Cheeseburger, chips, drink

$4.50

Grilled Chicken sandwich, chips, drink

$5.50

Vegetarian Salad and drink

(Please choose your dressing)

Ranch

Honey Mustard

Italian

1000 Island

No Dressing

$5.50

Late Registration Fee (For registrations postmarked after April 15, 2004.)

$25.00

Girl Scout Registration Fee (for non-registered Girl Scouts)

$10.00

TOTAL ENCLOSED

Funshop Selection: Write the funshop number in the corresponding block below. Every effort will be made to give you your first choice; however, please provide a 2nd and 3rd choice for each session.

Overnight Accommodations:

Who would you like for your roommate? (2 girls per room)

Funshop

First

Second

Third

Time

Choice

What would you like listed in the Attendee Listing?

Session #1

Your Name

o Yes

o No

Session #2

Your Address

o Yes

o No

Session #3

Your Phone Number

o Yes

o No

Session #4

Your Email Address

o Yes

o No

Chaperones and First Aiders

I have read the Chaperone Agreement. I would like to volunteer to be a chaperone and/or First Aider.

	I would like to be a chaperone on the Rockhurst University campus.			o Yes	o No
	I would like to be a chaperone on one of the excursions. I understand my admission fee will be paid for my excursion.			o Yes	o No
	I am certified in First Aid and willing to be the first aider at my off site excursion.			o Yes	o No
Special Needs - Please inform us of any special needs you have.
Dietary Needs:		Facility Needs:	Animal Assisted:

Adult Photo Release Permission Form

I, ________________________________, being of legal age, hereby consent that my name, image, and likeness, as shown in the photographs and/or motion picture or videotape in which I appear while attending Just for Seniors Getaway 2004, and any audio recordings made of my voice may be used by The Girl Scout Council of Mid-Continent Council, Just for Seniors Getaway 2004 staff, or Girl Scouts of the U.S.A., its assigns or successors, in whatever way they desire, including television and electronic media; furthermore, I hereby consent that such photographs, films, and recordings, and the plates and/or tapes, from which they are made shall be their property, and they shall have the right to duplicate, reproduce and make other uses of such photographs, films, recordings, plates, and tapes as they may desire free and clear of any claim whatsoever on my part.

In witness whereof I have hereunto set may hand, in the State of

on this day

Signature

Phone Number

Address

City

State

Zip

Girl Scout Travel Insurance

I understand before I will be permitted to attend Just for Seniors Getaway 2004, proof of Girl Scout Travel Insurance must be received at the address below prior to six weeks of the event (prior to 5/13/03).

Signature

My Mealtime "Chat & Chew" Discussion Suggestions are...

Please send completed registration form, health history record, & payment in full with a postmark by April 15, 2004. Space is limited to a total of 300 girls & adults. Registrants will be processed in order of postmark date until the space is full.

Check: Please make check payable to: Senior Girl Scout Getaway 2004

Mail to: Senior Girl Scout Getaway 2004, 11313 Riley, Overland Park, KS 66210-2655

Email us at: JustForSeniors2004@kc.rr.com

Getaway Website: http://www.oocities.org/justforseniors2004