Girl Scout Council of the Mid-South


	Program Event Registration

Instructions

Use this form to register Girl Scout troops/groups or individual girls for any council sponsored program activity. Use one form for each event. Honor the published registration information and dates for each activity.
Registrations will be accepted in order of receipt at the Girl Scout Service Center. The deadline is three weeks prior to event or when event is filled, unless specified otherwise.
Expect a confirmation packet with additional information no less than two weeks prior to event.

Fields marked with an asterisk * are required.

Event Name:*

Event Date:*

Location of Event:*

Person Coordinating this Registration:

First Name:*

Last Name*

Home Phone:*

Work Phone:*

Email:*

Address:*

City:*

State:*

Zip:*

Check One:*

Registering as Troop #
Registering as individual girl, (planning to attend without advisor).
(List names of each participant.)

Number of Girls by Age Level:*

Da. Br. Jr. Teen (age 11-17)

List name and phone number of any adults interested in helping with the event planning or sharing skills at the event?

Total

Ethnic/Racial Information
W-White B-Black A-Asian or Pacific Islander	AI-American Indian/ Alaskan Native H-Hispanic	O-Other M-Multi-racial

Any
Disabilities

Girl Participants

Girl Program Aides

Adults

Total Attendance

We welcome Girl Scouts with special needs. Please list their names and any special needs or restrictions we will need to accommodate:

Total Number of Girls:*	X (fee) =	$ Total
Total Number of Adults:*	X (fee) =	$ Total
Total Cost =		$

Payment*
Card Holder's Name:
Credit Card Type:	VISA MC
Credit Card Number:
Expiration Date:

You may submit form electronically by clicking submit or print and deliver to the
Girl Scout Council of the Mid-South
Mail: PO Box 240246, Memphis, TN 38124-0246
Deliver: 2715 Kirby Parkway, Suite 1
Fax: (901) 797-2183