www.girlscoutsla.org
6/2020 1
Whe
n Annual Permission form use is not given by parent/caregiver
Extended-Day Trips – (8+ hours) SUM or designee approval required prior to sending to parents
Short Overnight Trips – (1-2 nights) SUM or designee approval required prior to sending to parents
High-Risk – SUM approval only for Tier 1, SUM & Council (e-form) approval for Tier 2 high-risk activities, list on page 2
Extended/International Travel (3+ nights) (Sum, Go-Team, Council approval required) Fill out eform:
https://www.gsglavolunteerapps.org/extended-travelhigh-risk-application/
ET# _________________________
COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. As with any social activity,
participation in Girl Scouts could present the risk of contracting COVID-19. While GSGLA takes every safety and preventative
precaution, GSGLA can in no way warrant that COVID-19 infection will not occur through participation in GSGLA programs.
Activity Information
Date: _______________ Time: __________ Mode of transportation (walk, auto, train, etc.)______________________________
Destination Address: _________________________________________ City: _________________ State: _____ Zip: _________
Drop Off Location: ______________________ Time: __________ Pick up Location: ______________________ Time: __________
Activity Description: _ _________________________________________________________________________________________
Troop/Group Pays: __________ Family Pays: __________ Purpose of Fee: _____________________________________________
Please Bring: _________________________________________________________________________________________________
Troop Information Required
Troop/Group #: __________ Level(s): D B J C S A Service Unit: __________________________________
____________________________________________________________________________________________________________
Name of Leader or Adult in charge Phone E-mail Address
_ ______________________________________________________________________________________
Name of second Adult in charge Phone E-mail Address
_____ __________ __________ _________________________________
Emergency Contact Person for this activity (Adult who is not attending event/activity) Emergency Contact Phone
____________________________________________________________________________________________________________
Name of Certified First Aid/CPR/AED trained Adult (attending) Certification Expiration Date
Check ONLY requirements needed for this activity: GS training (Please indicate date training was taken)
Indoor Overnight: Name of Trained adult attending: _________________________________________ Date: __________
Camping Skills: Name of Trained adult attending: _________________________________________ Date: __________
Domestic Troop Travel: Name of Trained adult attending: _________________________________________ Date: __________
International Troop Travel: Name of Trained adult attending: _____________________________________ Date: __________
Lifeguard: Name of Certified adult attending: _________________________________ Certificate Exp: __________
Other Specialty Name of Certified adult attending: ________________________________ Certificate Exp: __________
Specialty: ___________________________________________________________________________________________________
I have reviewed Girl Scout procedures for this activity and agree to comply with GSGLA Volunteer Essentials and
Safety Activity Checkpoints___________________________________________________________________________
Signature of Leader or Adult in charge during Activity Date
_________________________________________________________________________________________________________
Signature of SUM or Designee Date Approved/Reviewed
Parent/Caregiver, please complete, sign and return this bottom portion only to Leader
Activity description: _______________________________________________________
My child ______________________________________ has my permission to participate with this Troop/Group in the above
activity on this date and time.
During the activity, I can be reached at: Phone: ___________________________Alternate Phone: __________________________
Name of alternate contact person (If I cannot be reached) ___________________________________________________________
Phone: __________________________________________ Alternate Phone: ____________________________________________
I have discussed appropriate behavior with my daughter. Also, I will make sure she does not participate if not feeling well.
___________________________________________________________________________________________ ______________
Signature of Parent/Caregiver Date
Parent/Guardian Single-Use Permission Form
This form is REQUIRED for every Extended-Day/Overnight/High-Risk activity or trip.
EMERGENCY: (877) 423-4752
