Individual Girl Program Registration

Me and Dad Under the Stars PROGRAM NAME

PAYMENT INFORMATION

April 20th Date of Program # Adults 1

1 # Girls

Location Coca Cola Science Center Time (Begin) 4pm Time (Ends) 10pm

25.00 25.00 x $ = $ 25.00 25.00 x $ = $ = $

Please q Register q Add on to Original Registration

x VISA MasterCard

Check/Money Order Cookie Dough

Account # Expiration Date / Madison Croasmun GIRLS NAME Name as it appears on card Signature Chatham Troop # 30078 County/Service Unit Security Code (3-digit number on the back of the card) Kat Leader/Advisor 11 5th Age Grade
203 Royal Oak Court Girl Scouts Address

Guyton, GA 31312
912-247-7644 Home Phone

WAITING LIST / REFUND

If the event is full, process my registration as follows: (check one) Waiting List Refund Transfer funds to another event (Name of Event) (Location) (Event Date)

Work Phone
912-247-7644 Cell Phone

mcroas@comcast.net Email Address

Send confirmation letter via (check one)

q E-mail q Mail

Indicate if Girl Scout participant needs the following: Wheel Chair Accessibility Physical Assistance Dietary Needs Financial Assistance *Please explain any checked items:

T-SHIRT SIZE (if included in the program fee)

Select T-Shirt Size (circle one):

qYS PERMISSION
My daughter has my permission to participate in the above Girl Scout activity. I shall make sure that she does not attend the event if she is ill.
Michelle Croasmun Parent/Guardian Signature
Digitally signed by Michelle Croasmun DN: cn=Michelle Croasmun, o, ou, email=mcroas@comcast.net, c=US Date: 2013.04.03 13:52:15 -04'00'

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Please submit this form with payment to the GSHG Program Registrar: programregistrar@gshg.org 508 Shartom Drive, Augusta, GA 30907 Phone: 706-774-0505 | Fax: 706-774-0045
Para la versin en espaol de esta forma, por favor visite www.gshg.org o su oficina local de Girl Scouts.

April 3, 2013 Date

It is advisable that an adult accompany the Girl Scout. If there is no adult that can accompany her we will attempt to place her with an age appropriate age level troop/group. All adults that attend the event are required to pay the event fee.

FOR OFFICE USE ONLY

Date/Time Received Trans # Initials $

Kirk D Croasmun Name of Accompanying Adult Total: Girls Adults 912-433-3449 Phone Refund / Transfer - Date

Trans #
GSHG FORMS (10/12)