2021 Camp Program Application
Program Name Dates Price
Registrant Name
Address
City State Zip
Day Phone Evening Phone
Primary Email (for conrmation info)
Grade in 2021-2022 school year Birthdate
Custodial Parent/Guardian Relationship
Day Phone Evening Phone
Email
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/Pacic 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 briey describe below. To further discuss an
accommodation, please contact the Answer Center, 314.400.4600 or email
answercenter@girlscoutsem.org
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
ZAP
Broadway Blast
InSPAaration
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
