2021 Resident Camper Information
Camper’s Name:
Camp:
Session Name:
Last First
Cedarledge
Tuckaho
Grade in Fall 2021
Custodial Information:
Who has custody of camper during camp session?
Both Parents Mother only Father only Other:
Mother’s/Legal Guardian’s Name:
Address:
Day Phone:
Evening Phone:
Cell Phone:
Father’s/Legal Guardian’s Name:
Address:
Day Phone:
Evening Phone:
Cell Phone:
Name of Emergency Contact (If custodial parents/legal guardian can’t
be reached)
Address:
Relationship to Camper:
Day Phone:
Evening Phone:
Cell Phone:
LastFirst
First Last
Camper eats: moderately much little often
Describe food allergies or dietary restrictions:
(such as diabetic, kosher, vegetarian, etc.)
Has camper ever been to an overnight camp for more than two days?
If yes, where and how long?
Describe camper’s previous camp experience: (day, troop or resident camp,
camping with other groups/family etc.)
Does camper make friends: easily fairly easily
with difculty with own age
with older children
Is camper afraid of: the dark animals
water other fears
Sleep habits: light heavy
sleep walker nightmares other
yes no
Sunscreen and Insect Repellent: As a parent/guardian, I accept responsibility for teaching
my daughter how to apply sunscreen and insect repellent, and will make sure my daughter
is appropriately dressed for outdoor activities. I will provide sunscreen and insect repellent.
I understand the above information will be shared only with my daughter’s counselors and
the camp administration. The camp staff will make every effort to protect personal health
information and will only disclose such information to health care professionals providing
treatment.
This health history is correct and my daughter has permission to engage in all prescribed
activities, except as noted by me and the licensed physician. The Girl Scouts of Eastern
Missouri has my permission to treat and/or transport my daughter to the hospital or doctor
for medical treatment should there be an illness or injury.
Media Permission: � I wish to opt out at this time.
Additional Comments:
Signature of Custodial Parent/Legal Guardian Date
pg. 2 of 2
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 authorized by this Release and
any use of the Media by GSUSA / GSEM.
Describe any past illness or disability that might limit her activity:
Describe personal experience(s) camper has dealt with in the past
year which may affect her behavior at camp: (such as death of a
relative, divorce, school problem, loss of a pet, etc.)
Signature of Custodial Parent/Legal Guardian Date
Signature of Custodial Parent/Legal Guardian
Date
