RESIDENT CAMP REGISTRATION FORM
R EG IS TR AT IO
N
VISIT WWW.GSOH.ORG FOR REGISTRATION INFORMATION. PRINT NEATLY OR TYPE. USE BLUE OR BLACK INK.
Girl’s name__________________________________________________Age________________
OFFICE-USE-ONLY
(at time of camp)
Street address__________________________________________________________________
Date received
City____________________________________________State_________ZIP_______________
Financial assistance
Home phone (
Deposit
) _________________________________
Parent/Guardian daytime#____________________________Cell phone:__________________
Program fee
Parent/Guardian daytime#___________________________Cell phone:___________________
Confirmation sent
Parent email address: ____________________________________________________________
Balance paid
Grade completed by summer____________________ Birthday ________/________/________
Late fee Horse
Please check if: Non-Ohio’s Heartland Girl Scout ____________________________________ (council where registered)
SESSIONS
1ST CHOICE
Bus
No No
2ND CHOICE T-SHIRT SIZE Any registration recieved before ApriL 1st includes a free T-shirt.
Dates Name of program Riding bus ($40)?
Yes Yes
Balance due
Yes
No
If yes, check bus stop: Columbus
Yes
No
Delaware
Youth YS
YM
YL
Adult AS
AM
AL
AXL
CAMPING I wish to share a tent/cabin with (list only ONE person)____________________________ Are special accommodations needed? (Sign interpreter, brailled materials, etc.): _________________________________________________________________________
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 Fax: 614-487-8189
IF CUSTODIAL PARENTS CANNOT BE REACHED, PERSON TO BE NOTIFIED IN CASE OF EMERGENCY:
Resident Camp Deposit
40.00 = $ _____________
Home phone (
Bus fee
40.00 = $ _____________
Cell phone (
Name________________________________________________________ Street address_________________________________________________ Daytime phone (
TOTAL INCLUDED = $ _____________
)__________________________________________ )____________________________________________ )______________________________________________
If custodial parents will be out of town during camp, where can you be reached?
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).
Address______________________________________________________
VISA MASTERCARD DISCOVER AMERICAN EXPRESS
Phone (
$ Amount
Expiration date
Billing address
Account number (typically 16 digits)
Signature of card holder (required for credit card payments)
City
Questions? Call 614-487-8101 or email corahelp@gsoh.org
State
Date
ZIP
City ________________________ State________ ZIP________________ )_________________________________________________