EmailMe Form - High Adventure Activity Application

Responsible Adult in Charge: *
First Last
Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone:
### - ### - ####
Email Address: *

(please re-enter email to confirm)
Troop Number:
Troop Level:
Daisy
Brownie
Junior
Cadette
Senior
Ambassador
Daisy Scouts can participate in High Adventure allowed by GSUSA Safety Activity Checkpoints.
Service Unit: *
If "OTHER" Please explain below:
Date of GSOC background clearance:
MM / YY
Anticipated dates of activity:
Activity Location:
Name of Certified First Aid Provider:
Level of Certification:
Level 1
Level 2
Certifying Agency:
Expiration Date on Card:
MM / DD / YYYY
Name of Adult Lifeguard (if required):
Expiration Date on Card:
MM / YY
Please check all activities that apply:
Archery
Backpacking
Bicycling with Rentals
Boating
Canoeing
Caving
Challenging Courses
Fishing with Vendor
Go Carts
Horseback Riding
Ice Skating
Kayaking
Knife Throwing, Tomahawk Throwing and Zorbing
Rappelling
Rock Climbing
Roller Skating
Sailing
Scuba Diving
Segway
Skiing
Sledding
Snowboarding
Snowshoeing
Snow Tubing
Surfing
Water Skiing
White River Rafting
Ziplining
Other (please specify):
Other High Adventure Activity:
Company/Private Instructor Name:
Contact Person:
Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone:
### - ### - ####
Email Address:
Check all that apply: *
I have read and will adhere to all guidelines in Girl Scout Safety Activity Checkpoints, Volunteer Essentials and Policies and Standards
Company is currently approved by GSOC
Company is currently NOT approved by GSOC
I have current Health History and Permission Slip forms for all girls in troop/group.
All girls in troop/group are prepared for this activity both physically and mentally
I have given a Safety Briefing to all attending Responsible Adults
Safety Activity Checkpoints [https://www.girlscoutsoc.org/content/dam/girlscoutsoc/documents/Safety-Activity-Checkpoints.pdf]
File Upload
Signature: *
Clear
By submitting this form, I confirm that the information in this form is correct to the best of my knowledge.
File Upload
If facility requires a signed form for use of their facility; upload the document here. The forms must be signed by an authorized GSOC representative (even if you already signed it). This review is required as it is GSOC procedure, don't assume personal risk when GSOC will assume the risk for you. We're looking out for you! (tip - scan all pages into one document).