Participant’s Name________________________________
October 1, 20____ to September 30, 20____
Complete this form annually at the time of registration. This is retained by the Troop/Group Leader. Parent/guardian should keep a copy of this form and
the attached Health History for use when their daughter/ward is attending an event without her troop
.
Name of Girl Scout Date of Birth Troop #
Address City State Zip
Printed Name of Parent(s)/Guardian(s) Relationship to Child
Email Address Primary Phone Secondary Phone
Emergency Contact Name Emergency Phone Relationship to Child
Emergency Contact Name Emergency Phone Relationship to Child
Please list adults that are permitted to pick up your daughter from Girl Scout activities, in the event you are unable to. These individuals
must be different from your emergency contacts:
__________________________________________________ _______________________________ Yes No
Name Cell Phone Receive text messages
__________________________________________________ _______________________________ Yes No
Name Cell Phone Receive text messages
Yes No
Initials_____
Permission for Troop and Council-Sponsored Activities: My daughter/ward has permission to travel to, attend and participate in troop
and council-sponsored activities that are 1) located within the Council’s jurisdiction and 2) not considered high risk activities.
Initials_____
Permission to Participate in Product Programs: My daughter/ward has permission to participate in the fall product and cookie programs,
including online programs. I agree to accept full responsibility for all product ordered and all money she receives and to assist her in making
prompt payment for product entrusted to her. I understand that all money collected by my daughter/ward belongs to Girl Scouts of Eastern
Missouri and her Girl Scout Troop and is not to be retained by individuals as their property. I understand that product cannot be returned or
exchanged. I understand that my daughter/ward may not take product orders before the official start of the product program as determined
by Girl Scouts of Eastern Missouri. Any parent or volunteer with an outstanding Troop Late Payment Report or delinquent balance owed to
Girl Scouts of Eastern Missouri will have a restriction of No Funds Handling placed on their account. A No Funds Handling restriction
prevents the parent or volunteer from participating in any role that is responsible for managing product or funds, including having access to
bank accounts. Because unpaid balances can serve to reduce our resources to provide services to girls, we pursue all debts vigorously.
Failure to successfully resolve debts in a timely manner can result in prosecution.
Initials_____
Permission for Emergency Medical Treatment: In the event of an emergency, every effort will be made to contact a parent/guardian or
emergency contact. If no contact can be made, I hereby give authorization to Girl Scouts of Eastern Missouri to seek treatment for my
daughter/ward by a licensed physician pursuant to Missouri law (RsMO 431.061.1). I know of no reasons why my daughter/ward may not
participate in prescribed activities except as noted on the Health History Form.
Initials_____
Media Permission
For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent and agree to the
following:
1. I hereby grant to Girl Scouts of Eastern Missouri (“GSEM”), and its 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 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 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 GSEM.
A completed Girl Health History form on the reverse side is required.
Special Accommodations: My daughter/ward requires the following special accommodations (write “none” if there are none):
Parent/Guardian Agreement: I have read and understand the Girl Health History and Annual Permission Form. I may change or
revoke any aspect of this agreement at any time by submitting my request, in writing, to the troop/group leader.
_
Signature of Parent/Guardian Date
F-57 - Revised 6/2019
