Destination (place name & address):                 Mt . Madonna Park, Wastonville, Santa Cruz 

Departure Date:                  Sept. 2,06 Time:10:00 am                          Place: Overfelt Garden, 2145 Mc Kee Rd, San Jose 

Return Date:                       Sept. 4,06 Time:2:00 pm                             Place: Overfelt Garden, 2145 Mc Kee Rd. San Jose 

Type of Activity Planned:      Camping 

Items to bring: Tent, Clothes, Camping gear 

What to Wear: Uniform                  Cost: $30 

In case of delay, the leader will notify:       Biện Thị Quý                  408-410-7542 

(This person will notify you.) Name_______________________________________ Phone_________________________________

KEEP THIS SECTION

COMPLETE, SIGN, AND RETURN THIS SECTION TO LEADER BY 

GIRLS NAME:________________________________________________________________________________________________________ 

PARENT/GUARDIAN’S NAME:_________________________________________________________________________________________ 

ADDRESS:____________________________________________________________________________________________________________ 

CITY: ______________________ZIP_____________________________________________________ 

PHONE: (Home)_______________________________   (Parent’s Work)___________________________________________________________  

Phone where Parent can be reached in case of emergency or delay:________________________________________________________________ 

Other Authorized Adult:__________________________________________________ Phone:___________________________________________ 

My daughter has my permission to participate in the following activity:_____________________________________________________________ 

   on the following dates: ____________________________________________________________________________________________________

Please provide the following information unless it is the same as on the Health History Record.

Physician Name :  _____________________________________________________       Phone_____________________________________________

Dentist:  Name___________________________________________________________ Phone______________________________________________

Insurance name and Policy #:__________________________________________________________________________________________________  

Special Medical Considerations: _________________________________________________________________________________________________

Medications or Prescriptions currently being used:__________________________________________________________________________________ 

Illness or surgery that would affect your daughter’s participation in this activity: ________________________________________________________ 
 

I will not allow her to attend if she is not feeling well.

Parent/Guardian Name _____________________________ I, being the parent/guardian of _______________________, hereby consent that the videotapes, photographs, motion pictures, electronic images and/or audio recordings of my daughter/dependent may be used by Girl Scouts for Public Relations and Publicity purposes. Parent/Guardian initials_______

In the event of an emergency, every effort will be made to contact a parent/guardian or emergency contact. If no contact can be made, I hereby give authorization to Girl Scouts of Santa Clara County to seek treatment for my child and/or dependent minor or myself by a licensed physician pursuant to Section 6910 of the California Family Code. I know of no reason(s), other than the information indicated on this form, why my daughter/dependent or I should not participate in prescribed activities except as noted.

Parent/Guardian Signature:_____________________________________________________________ Date______________________________