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Just for Seniors Senior Girl Scout
Conference GIRL Registration Form |
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Please PRINT
clearly.
Name |
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Troop # |
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Council |
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Years in
Girl Scouting |
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Address |
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Grade in
Fall 2004 |
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City,
State ZIP |
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Date of
Birth |
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Telephone # |
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What's your Shoe Size? (Please circle) |
Small (5-6) |
Medium
(7-8) |
Large (9-10) |
XL (10-13) |
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Fax
Number |
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Email
Address |
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Fax or email will be used to send you confirmation of your registration. |
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Travel Information I will be arriving in |
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I'll be arriving on (Date) ____/____/04 at (Time) |
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I'll be leaving on (Date) ____/____/04 at (Time) |
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Cost |
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Conference Fee (includes conference
materials, 7 meals, excursion transportation, overnight accommodations for 3
nights) |
$150.00 |
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Conference Souvenirs - Must be ordered by |
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a)
Just for Seniors Patch |
# |
Quantity |
x |
$1.50 |
Each |
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b)
Just for Seniors Pillowcase |
# |
Quantity |
x |
$6.00 |
Each |
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c)
Just for Seniors T-Shirt |
Small |
Medium |
Large |
1X |
2X |
3X |
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(Please indicate quantity & size) |
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Quantity |
x |
$9.00 |
Each |
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d)
Just for Seniors Drawstring Backpak |
(check your color choices) |
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Purple |
Lime Green |
Sky Blue |
Lemon Yellow |
Fuchsia |
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Outside
Backpak Color |
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Inside
Backpak Color |
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$10.00 |
Each |
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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 |
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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 |
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A-1 Oceans of
Fun |
$17.00 |
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A-2 Worlds of
Fun |
$17.00 |
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A-3 Canoeing
Trip |
$10.00 |
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A-4 |
$10.00 |
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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 |
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Morning Half-Day
Excursions |
Choice # |
Afternoon Half-Day Excursions |
Choice # |
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B-1 |
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C-1 AMC 20 Movie |
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B-2 |
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C-2 |
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B-3 |
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C-3 |
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B-4 |
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C-4 Oak Park Mall |
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B-5 Steamboat |
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C-5 Pepsi Ice |
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B-6 |
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C-6 Union Station |
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B-7 Truman Library/House |
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C-7 |
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Lunch in the Park –
Please select your lunch preference if you participate in half-day
excursions. |
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$3.50 |
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$4.50 |
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$5.50 |
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(Please
choose your dressing) |
Ranch |
Honey Mustard |
Italian |
1000 |
No
Dressing |
$5.50 |
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Late Registration Fee
(For registrations postmarked after |
$25.00 |
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Girl Scout Registration
Fee (for non-registered Girl Scouts) |
$10.00 |
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TOTAL ENCLOSED |
$ |
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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. |
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Overnight Accommodations: Who
would you like for your roommate? (2 girls per room) |
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Funshop |
First |
Second |
Third |
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Time |
Choice |
Choice |
Choice |
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What
would you like listed in the Attendee Listing? |
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Session #1 |
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Your Name |
o Yes |
o No |
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Session #2 |
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Your Address |
o Yes |
o No |
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Session #3 |
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Your Phone Number |
o Yes |
o No |
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Session #4 |
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Your Email Address |
o Yes |
o No |
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Special Needs - Please inform us of any special needs you have. |
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Dietary
Needs: |
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Facility
Needs: |
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Animal
Assisted: |
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Girl Photo Release Permission Form
I, being Parent/Guardian of _____________________________________,
hereby consent that any of her photographs and/or motion picture or videotape
in which she appears while attending Just for Seniors Getaway 2004, and any
audio recordings made of her 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 |
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on this day |
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Signature
of Parent/Guardian |
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Phone
Number |
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Address |
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City |
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State |
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Zip |
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I
have read the information describing the Just for Seniors Getaway 2004
Conference and give permission for my daughter to participate in all activities
except any listed below. |
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Restricted Activities: |
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Parent/Guardian
Signature |
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Date |
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My daughter can participate |
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Yes |
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No |
My daughter is a |
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non-swimmer |
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beginner swimmer |
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skilled swimmer |
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Girl Scout
Travel Insurance
I understand before my
daughter 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
Signature
of Parent/Guardian |
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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,
Email us at: JustForSeniors2004@kc.rr.com
Getaway Website: http://www.oocities.org/justforseniors2004