~ CMP ALUMNAE WORK WEEKEND Registration Form ~

OCTOBER 13-16, 2016

(Arrive 13th, Work 14-15th, Depart 16th)

NAME OF ADULT(S) ATTENDING: (Due to safety reasons, participants must be 18 years of age.)
_____________________________________
Registered Girl Scout

Alumnae

______________________________________

Troop Mitre Member

Registered Girl Scout

Alumnae

Troop Mitre Member

ADDRESS: ________________________________________________________________________________
CITY/STATE: __________________________________________________________ ZIP: _________________
HOME PHONE: ________________________________

CELL PHONE: _________________________________

EMAIL ADDRESS: ____________________________________________________________________________

ESTIMATED TIME & DATE OF ARRIVAL: __________________ ESTIMATED TIME & DATE OF DEPARTURE_______________________
LODGING PREFERENCE: Ms. Effies Health Center Kiva (please reserve these for participants with health/mobility concerns)
Kickapoo cabin Seminole/Apache cabin RV Hookup Will be lodging elsewhere

DESCRIBE ANY SPECIAL DIETARY REQUIREMENT(S):_____________________________________________________

EMERGENCY CONTACT~ NAME: _________________________________________________________________
PHONE: _________________________________
OTHER PHONE: _________________________________

Yes, I want to help at CMP Work Weekend! (Price includes 7 meals ~ 3 meals Fri. & Sat, Sun. breakfast)
Food & Lodging: $35 per person (Alternate Rate: $20 for unemployed/senior/college student) $_________
Yes, I would like to join Troop Mitre! Sign me up!
Membership dues: $60 along with GS membership of $15, if not already a member $_________
(Alternate rate: $25 for unemployed, senior/college student)

Yes, I would like to make a contribution to Troop Mitres Feed the Flame fund in
support of Camp Mitre Peak!
$_________
DEADLINE TO REGISTER:

FRIDAY ~ OCTOBER 5th

TOTAL ENCLOSED:

$____________

AUTHORIZATION TO CHARGE:
NAME ON CARD: _________________________________________________ CARD # ____________________________________
I AUTHORIZE GSDSW TO CHARGE MY CREDIT CARD: $________
EXP. DATE ____/____ 3 DIGIT SECURITY CODE ________

CHECK ONE: VISA MASTERCARD DISCOVER AMEX

SIGNATURE OF CARDHOLDER: _______________________________

MAIL THIS FORM AND TOTAL FEE TO: (Checks payable to GSDSW)
Girl Scouts of the Desert Southwest, CMP Work Weekend, 5217 N. Dixie, Odessa, TX 79762

SPONSORED BY: