2021 Camp Program Application
Program Name Dates Price
Registrant Name
City State Zip
Day Phone Evening Phone
Primary Email (for conrmation info)
Grade in 2021-2022 school year Birthdate
Custodial Parent/Guardian Relationship
Day Phone Evening Phone
Girl Scout Membership: All girls who attend camp programs must be Girl Scout
members for the current membership year (10/1/20-9/30/21). The cost for
membership is $25. Complete this section if the camper is not currently a registered
Girl Scout.
I give my daughter, , permission to join Girl Scouts
of the USA.
Racial Ethnic Background (optional): The following information is requested only to
measure progress toward serving all girls in our jurisdiction.
White Black Asian Hawaiian/Pacic Islander Also Hispanic
American Indian/Alaskan Native
Disability Information: We welcome the participation of all girls and adults, and will
make reasonable accommodations to persons with disabilities. If in need of an
accommodation, please briey describe below. To further discuss an
accommodation, please contact the Answer Center, 314.400.4600 or email
Does your child need a reasonable accommodation?
Yes No
Parental Permission: I am the custodial or legal guardian of this applicant and have
read the program publication thoroughly. I understand and agree to follow all
procedures and guidelines. I give permission for my camper to attend camp and
participate in all phases of activities.
Parent/Guardian Signature
Media Permission:
I wish to opt out at this time.
Parent/Guardian Signature
(continued on next page)
I want to attend the following program:
(Check only one camp)
Day Camp
15 hours or less of programming
16 hours or more of programming
Aide Training - Camp Tuckaho
One-day of programming
Labor Day Family Camp
Camp Cedarledge
Camp Tuckaho
Camp Fiddlecreek
Pony Extravaganza
Camp Cowgirl
Flashlights and Fireflies
Jr. Jam
Mermaid Magic
Gritty Girls
Broadway Blast
Mountain Explorers
PJ Party
Pedal Power
Cycle the Cedars
Red, White & YOU
Teddy Bear Tea
Crafty Cedars
LEAP 1 & 2
Camp Sampler
She & Me
Just 2 of Us
Resident Camp Quest
Tuckaho Explorers
Brownie Discovery Day
Junior Discovery Day
Junior Sleepout
Horse Overnight
Older Girl Sleepout
Camp Fury STL
Catching Fury STL
Please complete separate applications for each registrant and program.
I hereby grant to Girl Scouts of the USA (“GSUSA”) / Girl Scouts of Eastern
Missouri (“GSEM”), and others working for GSUSA / GSEM or on its behalf, and
each of its respective licensees, successors and assigns (each a “Releasee”),
the irrevocable, royalty-free, perpetual, unlimited right and permission to use,
distribute, publish, exhibit, digitize, broadcast, display, modify, create derivative
works of, reproduce or otherwise exploit my name, picture, likeness and voice
(including any video footage of the same), testimonials (written by me or
attributed to me), interviews (written by me or attributed to me) (collectively,
“Media”), or to refrain from so doing, anywhere in the world, by any persons
or entities deemed appropriate by GSUSA / GSEM, for any purpose including,
without limitation, any use for educational, advertising, non-commercial or
commercial purposes in any manner or media whatsoever (whether known
or hereafter devised) including, without limitation, on the Internet, in print
campaigns, in-store and via television. I agree that I have no interest or
ownership in any of the Media.
2. I shall have no right of approval, no claim to compensation and no claim
(including, without limitation, claims based upon invasion of privacy,
defamation or right of publicity) arising out of any use, alteration, blurring,
illusionary effect or use in any composite form of my name, picture, likeness
and voice. I agree that nothing in this Release will create any obligation on
GSUSA / GSEM to make any use of the Media or the rights granted in this
Release. I hereby release and hold harmless Releasees from any claim for
injury, compensation or negligence resulting or arising from any activities
Method of PaymentAll monies received are cashed or charged when received at Girl Scouts of Eastern Missouri.
Check all that apply:
Check or Money Order Debit Card  Visa  MasterCard Discover
Program Fee $
Non-refundable deposit- $50 per camp (Resident Camp only) $
Membership Fee -$25 (if not a registered Girl Scout) $
Additional Options (as selected below) $
Total Enclosed $
Credit Card Information
Account Number Expiration Date
Cardholder’s Signature Date
Activity Scholarship Form is attached
2021 Resident Camp T-shirt (included in program fee)
YS  YM  YL
2021 Resident Camp T-shirt $XX (not included in program fee for
Horse Overnight, She and Me, Just the 2 of Us)
YS  YM  YL
Day Camps (patch included in program fee)
Day Camps attending:
Interested in being an Aide (complete Volunteer Application)
Interested in being a full-time volunteer (complete Volunteer
Application--will qualify for daughter discount if application is
Interested in being a part-time volunteer (complete Volunteer
Application--will guarantee daughter spot in camp)
Day Camp - Pre/Post Camp
• Pre camp ($2 per day)
All ve days
Only on selected days:
• Post camp ($3 per day)
All ve days
Only on selected days:
Resident Camps
This camper attended a Resident Camp last year, qualifying for
a 15 percent discount this year
Buddy Request (list only one, buddies must list each other)
*naming a buddy does not guarantee placement except for Camp Mini.
Just the 2 of Us
A camper and their adult will have the option of staying together in a
tent or cabin when attending as a parent-child pair. If attending with
an adult other than a parent, or if preferred, girls will sleep in the
same unit, but not the same tent/cabin as their adult.
Troop Camp Blitz
Registering as an Adult Trainee
Registering as a girl to go with the following adult:
The Trainee listed will attend the required In-Town Training
Labor Day Family Camp
Please list names of all attendees and their ages:
Other families with whom you want to be placed:
Family Camp Housing Units
For Family Camp only—indicate 1
, 2
or 3
choices and number of
cabins or tents needed.
Lodge (20-30 people)
Cabin (4-8 people in each) # of cabins
Permanent Tent (4 people in each) # of tents
Specic Program Details/Additional Options
Resident Camps that
require the $50 deposit
Specialized Resident
Equestrian Programs
Leadership Programs