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2023 WAITLIST -Daisy/Brownie(K-3rd in Fall)
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* Indicates required question
Email
*
Your email
Last Name
*
This is the Girl Scout Camper Name
Your answer
First Name
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
IA
IL
WI
Other:
Zip Code
*
Your answer
Email (used for all camp communications)
*
Your answer
Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Grade in Fall
*
0-Kindergarden - Daisy
1st - Daisy
2nd - Brownie
3rd - Brownie
School
*
Your answer
Troop Number
*
Your answer
T-Shirt Size
*
Youth S
Youth M
Youth L
Other:
I will be using Virtual Program Credit
*
no
yes
If applying Virtual Program Credit, enter the Virtual Program Credit 19-Digit Account Number
Your answer
If applying Virtual Program Credit, enter the Virtual Program Credit CVV Code.
Your answer
If applying Virtual Program Credit, enter the dollar amount of Virtual Program Credit you wish to apply toward your Conestoga Day Camp balance.
Your answer
I will be applying for a grant for camp.
*
No
Yes
Allergies (animals, food, insects, medication, etc.) and how to respond to a reaction (if applicable). Please be specific.
*
Your answer
Dietary Restrictions, Medications, Physical Limitations or Other Concerns (if applicable). Please be specific.
*
Your answer
Height
*
Your answer
Weight
*
Your answer
Camp Buddy (if applicable)
Make new friends! Girls are grouped with someone else from their troop if possible, but troops with > three girls are split among units. Please select NO MORE THAN ONE camp buddy.
Your answer
Bus Buddy (if applicable)
Your answer
Verify Transportation
*
Old Hobby Lobby Bus
Northpark Mall Bus
Private Transportation
If you are riding the bus, would you consider riding the bus from the other location in order to balance rider distribution?
Yes
No
Maybe
Clear selection
Overnight
*
5th grade and older spend the night
N/A
Parent/Guardian Name
*
Your answer
Relationship
*
Your answer
Parent/Guardian Address
Needed only if different than camper
Your answer
Parent/Guardian Phone
*
Your answer
Parent/Guardian Alternate Phone
Your answer
Is this Parent/Guardian an Emergency Contact?
*
Yes
No
Emergency Contact #1 Name
*
Your answer
Emergency Contact #1 Relationship to Camper
*
Your answer
Emergency Contact #1 Daytime Phone
*
Your answer
Emergency Contact #1 Evening Phone
*
Your answer
Emergency Contact #1 Cell Phone
*
Your answer
Emergency Contact #2 Name
Your answer
Emergency Contact #2 Relationship to Camper
Your answer
Emergency Contact #2 Daytime Phone
Your answer
Emergency Contact #2 Evening Phone
Your answer
Emergency Contact #2 Cell Phone
Your answer
Insurance Provider
*
Your answer
Insurance Policy Number
*
Your answer
Insurance Group Number
*
Your answer
I give permission for my daughter to take over-the-counter medication(s) checked according to the manufacturer's instructions and at the dosage appropriate for her weight and/or age:
*
Acetaminophen (Tylenol)
Ibuprofen (Motrin)
Topical Hydrocortisone Cream (Cortizone)
Decongestant (Sudafed)
Antihistamine (Claritin)
Antacid (Tums)
Antidiarrheals (Pepto-Bismol)
Diphenhydramine (Benadryl)
Naphazoline/Pheniramine (Visine)
Antihistamine (Talcum Powder)
Expectorant (cough suppressant/cough drops)
Required
Type full name of parent/guardian to electronically "sign" the form.
*
Your answer
Enter today's date for confirmation of when health agreement and waiver was acknowledged.
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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