Return this form with the $25 deposit to GSSWGA, 515 Pine Ave., Albany GA 31701

Out of Council registrations will not be accepted until after April 1, 2005

 Resident Camp Registration

Girl’s Name___________________________________________________________________

Parent/Guardian Name__________________________________________________________

Street Address________________________________________________________________

City____________________  State____  Zip __________  Phone _______________________

Birthdate________________  Age at time of camp ______  Grade in fall___________________

Is camper a registered Girl Scout?   Yes  or  No                                    T-Shirt size ______

Girl Scout Troop #____ Program level in Fall:___  Brownie____ Junior___ Cadette/Senior___

Did your daughter attend Camp Okit in the summer of 2004?   Yes  or  No

Swimming Ability:___   Non-swimmer___  Beginner___  Intermediate     ___   Advanced

Mother’s place of employment _________________________________  Phone ___________

 Father’s place of employment_________________________________  Phone ___________

 Emergency Contact  ____________________________________  Phone ___________ 

 Is your family covered by medical insurance?   If so, what is the carrier and policy number?

___________________________________________________________________________

 Camp Session Choices:                                                      Dates

1st  _____________________________________________         ___________________ 

2nd  _____________________________________________         ___________________ 

 Camp Mate Choice ___________________________________________________________

 Does your daughter have any special dietary or physical restrictions? If so, please list.

___________________________________________________________________________________________

 Parental Permission

It is agreed that_____________________________________may participate in all camp activities, appear in photographs to promote Girl Scout program, and if needed, receive emergency medical treatment.

 Signature (parent/guardian)  __________________________  Date _________________