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Perfect North
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Bronze/Silver Award J/C
Bugs Badge B
Canvas Art C/S/A
First Aid Badge Workshop B/J
Destinations J/C/S/A
First Aid Badge Workshop C/S/A
Flowers Badge J
Gold Award S/A
Inventor Badge J
Space Science, Explorer D
Space Science, Adventurer B
Space Science, Investigator J
Procedures
Archery
Resource Rental Policy
Day Camp
Session information
Registration Information
Register for Day Camp
Calendar
Contact US
Fill Out sections below.
*
Indicates required field
Camper's Name
*
First
Last
Buddy's Name
*
First
Last
Must be in same age level; Only one buddy
Parent/Guardian Name#1
*
Day Phone Number
*
Parent/Guardian Name#2
*
Parent/Guardian Email
*
Cell Phone Number
*
Home Phone Number
*
Day Phone Number
*
Address
*
Please Register Me for: 1st Choice
*
Retro Mix
Super Silly Science
Please Register Me for: 2nd Choice
*
Retro Mix
Super Silly Science
City
*
State
*
Zip
*
Grade Entering in the Fall 2019 at the time of session:
*
Age at the time of session:
*
Troop/Group#
*
Service Unit
*
School District
*
School
*
Date of Birth
*
Age Level (Choose One)
*
Daisy
Brownie
Junior
Cadette
Senior
Ambassador
I am an out-of-council Girl Scout: Council Name
*
My Camper is under the custodial care of:
*
Mother Only
Father Only
Both Parents
Guardian
Program Assistance is available to help with day camp fees. For more information contact us at
lickingvalleypac@gmail.com
WellCare
and
Anthem Medicaid
recipients will have Girl Scout Membership Covered with copy of card presented.
Contact the Council at 1-800-475-2621, Option 2
Would you like to request Program Assistance?
*
Yes
No
Recipient Of:
*
WellCare
Anthem Medicaid
Day Camp Volunteer
Days you can help:
*
Monday
Tuesday
Wednesday
Thusrday
Friday
Session Date:
*
Volunteer Name
*
First
Last
[object Object]
Phone Number
*
Registered Girl Scout?
*
Yes
No
Volunteer Criminal Record Check Release Form on file?
*
Yes
No
Payment of Camp Fees
Total Cost of Session ($85)
*
Girl Scout Membership (+$10)
*
Additional Daughter Discount (-$5 if applicable)
*
$5 if applicable; only applies to add one girl
Cookie Dollars and Nut Bucks (-)
*
Program Assistance (-)
*
Late Fee ($10)
*
Other Info
My camper has permission to attend Day Camp and participate in all activities therein. This included field trips outside of campsite organized and under supervision of Day Camp staff. I believe my camper to be physically fit and not exposed to any contagious disease/infections.
*
I agree.
Photo Release: Permission for my camper's photo or likeness to be unsed in camp publications and promotions:
*
Yes
No
I understand the deposit of $25 is non-refundable.
*
Yes
No
I understand that by typing my full name I agree that all the information above is accurate and that a bill will be sent to me by Licking Valley PAC.
*
Date
*
Submit
Home
About
Programs
Ideas / Reference
Broadway Series
Perfect North
Request A Program
>
Bronze/Silver Award J/C
Bugs Badge B
Canvas Art C/S/A
First Aid Badge Workshop B/J
Destinations J/C/S/A
First Aid Badge Workshop C/S/A
Flowers Badge J
Gold Award S/A
Inventor Badge J
Space Science, Explorer D
Space Science, Adventurer B
Space Science, Investigator J
Procedures
Archery
Resource Rental Policy
Day Camp
Session information
Registration Information
Register for Day Camp
Calendar
Contact US