Program registration form

Program Registration Form

Please use a separate form for each event. Duplicate as needed or download from gsoh.org BASIC INFORMATION

EVENT DETAILS

Parent/Volunteer Name_________________________________

Name of Event________________________________

Address_______________________________________________

Date______/______/______

City____________________________State______ZIP_________

Time__________________

County________________________________________________

Location______________________________________

(H) Phone _________________ (W)Phone ___________________ Email address:_________________________________________

# Attending

Troop Number________________Service Unit______________

Girls ________ x __________________ = ___________

Grade level of girl/troop: (check one)

Adults ______ x __________________ = ___________

Fee

 K-1  2-3  4-5  6-8  9-10  11-12 Special needs? (Sign interpreter, braille materials, etc.):

Amount Due

= ___________

_______________________________________________________

NEW MEMBER?

PAYMENT METHOD

All you need to do is attach the Membership Registration Form and your membership fee! The form can be found at www.gsoh.org.

Check or Money Order

$ ___________

C a sh (Do not send in mail.)

$ ___________

FOR REGISTRATION PURPOSES: List names of girls, adults, and family members who will be attending the event (please include names of adults even if they are not paying a fee).

Financial Aid (Completed Financial Assistance form must accompany this registration form.)

$ ___________

Credit Card (Complete information below.)

$ ___________

TOTAL ENCLOSED

$ ___________

Reward Cards

$ ___________

Last Name

First Name

Girl/Adult

_______________________________________________________ _______________________________________________________

(Circle one)

_______________________________________________________

VISA Master Card Discover American Express

_______________________________________________________

Account number Billing Address

_______________________________________________________ _______________________________________________________

Expiration Date

Street________________________________________ City___________________________ ZIP___________ Signature_____________________________________ (Required for credit card orders)

_______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

Make check payable to: Girl Scouts of Ohio’s Heartland Council, Inc. Mail to: Girl Scouts of Ohio’s Heartland Council, Inc. 1700 WaterMark Drive Columbus, OH 43215-1097 Fax: 614-487-8189 Phone: 614-487-8101

PLEASE ALLOW THREE WEEKS FOR CONFIRMATION