SECTION 1 - Required for all activities/trips

Service Unit Name: Service Unit #: Troop #:

Name of Adult Advisor:

Address: Phone (h):

City: State: OH IN KY Zip: Phone (w):

E-mail address: Cell phone:

Age Level: Select Age Level Daisy Brownie Junior Cadette Senior STUDIO 2B # of girls: # of adults:

Are all participants Girl Scout members? Select Choice Yes No   If NO - special activity insurance is required.

Type/Length of Activity/Trip (see chart above) Select type of trip High Risk Activity Day activity - over 30 miles Trip less than 100 miles Trip over 100 miles Trip budget per person exceeds $300

SECTION 2 - Activity Information - Required

Name of Activity/Trip: Date(s):

Name of Facility: Facility phone #:

Facility Address:

Name of Qualified First Aider: Certification type:

Will you be doing the following activities?       Horseback riding  No Yes   Swimming No Yes Boating No Yes

Skiing No Yes Caving No Yes

Name of Lifeguard if swimming/boating:

High Risk Activity form completed for each girl (if needed)? Select a choice Yes No   (keep these with you)

Certificate of Insurance on file at the Girl Scout Center? Select a choice Yes No (required for all High Risk activities)

Have you purchased additional insurance (if needed)? Select a choice Yes No

SECTION 3 - Transportation

If using private or leased vehicles please list drivers below and submit proof of insurance to the Girl Scout Center.

Mode of Transportation: Select mode of transportation Private vehicle Leased/rented vehicle Chartered bus Train Plane

Troop leader has verified that all trip drivers meet the requirements of the Volunteer Driver Policy as printed in Section H of the Adult Resource Manual.  Select choice Yes No

SECTION 4 - Trip Information

Departure Date: Time:   Return Date: Time:

Trip Itinerary:  Please list all major activity locations and hotels, etc. 

Emergency Contact on the trip:  where you can be reached on the trip

Name:

Phone #'s:

Address:

Emergency Contact Person at home while you are gone

Name:

Phone #'s:

Address:

SECTION 6 - Money

If the cost per individual is $300 or more - troops must also submit a Troop Trip Budget Worksheet.  Links to the Troop Trip Budget Worksheet (both downloadable and on-line versions) will be available on the confirmation page that will appear after you submit this form.