Application for Troop Travel/Overnight/Special Activity Please complete this form if: your activity involves overnight, troop trips, and troop camping or special activities requiring council permission as listed in Volunteer Essentials and Safety Activity Check Points. Please type or print. Complete all information. Submit for approval. Troop #____________ Service Unit ___________________________________________ (Circle or Check) DS BR JR CD SR Leader’s Name ______________________________________________ Phone # Work________________ Home__________________ Address/City/State/_____________________________________________________________________________ Zip ______________ Event __________________________________________________Trip Dates_________________________________20________ # of Girls attending:_______________ # of Adults attending:_______________ # of vehicles:_______________ 3. Location (include Hotel name, address, phone #, room #, ranger station, site #, etc.) REQUIRED ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ 4. Schedule (places, dates, major activities): You Must Attach A Complete Schedule of Events, Troop Roster, & Permission Slip 5. Anticipated Expenses: Total Cost $_________________ To Troop $_______________ Per Girl $__________________ 6. Transportation:  Requesting Council permission for leased vehicles __________________________________________________________________ Method of Transportation (Must be secured in advance)  Private Vehicle  Leased Vehicle (Signature of Executive Director/President Grants Permission)  Commercial Plane  Leased 15 Passenger Van (Refer to special policies)  Extra Insurance has been purchased:  Plan 2 (over 72 hours or non-registered members) - required  Plan 3 (extra coverage for illness) – optional List Name of trained Adult (s) in Attendance Name ____________________________________________________________ Indicate certification date: Name ____________________________________________________________ Indicate certification date: Phone #________________________________ CPR/FA____ JUMPSTART____ LEADERSHIP ESSENTIALS ____ SIMPLE OVERNIGHT____ SIMPLE CAMPER_____ Phone #________________________________ CPR/FA____JUMPSTART_____ LEADERSHIP ESSENTIALS____ SIMPLE OVERNIGHT____ SIMPLE CAMPER_____ _____ I have read all appropriate standards in Safety Activity Checkpoints and the council Policies & Procedures and agree to adhere to them. (Initial) _____ I have attached documentation for special activity as required. (Certification copy must be attached). (Initial) Attached is a copy of my permission slip, roster of all girls/adults attending and schedule of activities. CELLULAR PHONE NUMBERS ARE NOT ACCEPTABLE AS CONTACT NUMBERS (UNLESS THERE IS NO OTHER PHONE) Emergency Contact at Home: Name ________________________________________________________________________ Phone # ________________________ Address/City/State/Zip __________________________________________________________________________________________ Emergency Contact at Destination: Name ________________________________________________________________________ Phone # ________________________ Address/City/State/Zip __________________________________________________________________________________________ I will verify all vehicles and drivers are currently registered and insured according to Girl Scouts of Southern Nevada’s policy as stated in the Leadership Essentials and Activity Safety Check Points. I will assure the number of passengers does not exceed the number of seatbelts available. I have read all appropriate standards inactivity Safety Check Points and the council policies and agree to adhere to them. Signature of Troop Leader______________________________________________________________________ Date _________________________ Signature of Membership Staff __________________________________________________________________ Date _________________________ This form to be completed and given to your Membership Staff four (4) weeks prior to event for approval. Please check for accuracy! Misinformation could result in Girl Scout Activity Insurance coverage not being valid for this trip and/or increased personal liability. 08/12 pc 2941 Harris Avenue Las Vegas Nevada 89101 702 385 3677 girlscoutsnv.org TP-16