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We are registered as a Girl Scout Troop. (Girl Scouts of Eastern Missouri)

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C-009
KK/sa 3/11/2016
revised 10/25/2018
Girl Scouts of Eastern Missouri
2300 Ball Drive
St. Louis, MO 63146
314.592.2300 • 800.727.4475
girlscoutsem.org
APPLICATION FOR ALL CAMPING ON
NON-COUNCIL-OWNED SITES
IS YOUR GROUP ELIGIBLE FOR A NON-COUNCIL-OWNED SITE CAMPING TRIP?
□ We are registered as a Girl Scout Troop. (REQUIRED) See Safety Activity Checkpoints and Girl Scout Volunteer
Essentials for more information.
• Adults supervising a Girl Scout camping activity must be registered, background checked and approved prior to
participation
□ This is a troop camping experience of less than one week in duration that takes place within, or no more than 100
miles beyond Girl Scouts of Eastern Missouri boundaries. (If the trip is more than 100 miles beyond Girl Scouts of Eastern
Missouri boundaries, please use the Troop Trip Application process.)
APPLICATION PROCEDURE:
1. This application must be submitted at least ONE month prior to the camp trip date.
2. A troop camp-certified adult must accompany the group. Submit a copy of the certification with this application.
3. A certified First Aider must accompany the group if the destination is less 30 minutes away from EMS. To be a First
Aider the individual must have both first aid and Adult and Child CPR/AED certifications from a Council-approved
agency. These certifications cannot be split up between individuals attending the activity.
The following healthcare providers may also serve as First Aiders: physician, physician’s assistant, nurse practitioner,
registered nurse, licensed practical nurse, paramedic, military medic and emergency medical technicians who have
current certification in Adult and Child CPR/AED.
4. For those destinations whose access to EMS is 30 minutes or more, an individual certified in Wilderness First Aid is
required. Submit a copy of the certification with this application.
5. Unless the troop is using a Missouri State Park, Girl Scouts must have a Certificate of Insurance (COI) on file for the
property used for the activity. If the property used does not currently have a COI on file, submit a copy with this
application. A list of current COIs on file at Council can be found at www.girlscoutsem.org.
6. Applications must be submitted with your Neighborhood Manager's signature.
7. Keep a copy of this application, and mail the original with copies of certifications and COI if applicable to:
Girl Scouts of Eastern Missouri
Attn: Director, Camping Services & Risk Management
2300 Ball Drive
St. Louis MO 63146
After the Camp Department has received your application, you will receive, via email, a NON-COUNCIL-OWNED
CAMP APPROVAL RESPONSE indicating the status of this application.
C-009
KK/sa 3/11/2016
revised 10/25/2018
Girl Scouts of Eastern Missouri
2300 Ball Drive
St. Louis, MO 63146
314.592.2300 • 800.727.4475
girlscoutsem.org
APPLICATION FOR ALL CAMPING ON
NON-COUNCIL OWNED SITES
Date Submitted Troop # District Neighborhood Program Level
TROOP LEADER or TRIP ORGANIZER:
Phone: Cell phone:
Address:
City, State, Zip:
Email:
CAMPING TRIP: Date of Departure: Date of Return:
Destination: City, State, Zip:
Owner/operator of camping trip destination:
Number of girls registered in troop Number of girls going Ages Number of adults going
Certificate of Insurance is enclosed Certificate of Insurance is on file with Girl Scouts
PURPOSE OF CAMPING TRIP:
CAMP ACTIVITIES: Check those activities in which you expect to participate:
Swimming Boating Other:
ADULTS: Complete where applicable:
Certified First Aider (Copy of First Aid, Adult CPR/AED and Child CPR/AED certifications required for processing.
Wilderness First Aid is required when access to EMS is 30 minutes or more away from the trip’s destination):
Name:
Address: City, State, Zip:
Expiration date of certification: Adult CPR/AED Child CPR/AED First Aid
Troop Camp Certified Adult (Copy of certification required for processing):
Name: Address:
City, State, Zip:
Type of Certification:
Troop Camp A – Z Troop Camp Fast Track
C-009
KK/sa 3/11/2016
revised 10/25/2018
Lifeguard (Copy of Red Cross certification required for swimming & boating if site does not provide personnel as required
by Safety Activity Checkpoints):
Name: Address:
City, State, Zip:
Certified Small Craft Safety Personnel (Copy of Red Cross certification required for boating if site does not provide
personnel as required by Safety Activity Checkpoints):
Name: Address:
City, State, Zip:
Other Adults (list names and addresses):
Name and phone number of nearest hospital/clinic:
Applicable emergency (ambulance, police/sheriff) phone numbers (911 service or local numbers):
Time to access EMS services if needed?
Contact Person: Person to be contacted in case of emergency and available during entire time of trip:
Name:
Home Phone: Work Phone:
Cell Phone:
Address: City, State, Zip:
District/Neighborhood Manager’s Name (print):
District/Neighborhood Manager’s Signature: Date:
Phone: Email Address:
D/N Manager’s Comments: I have reviewed this application and endorse the plans with the following comments:
Troop Leader or Trip Organizer Signature: Date:
Keep a copy of this application and mail original with certification copies to:
Girl Scouts of Eastern Missouri
Attn: Director, Camping Services & Risk Management
2300 Ball Drive
St. Louis MO 63146
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Completed 9 May 2021

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