GIRL SCOUTS OF NORTHERN NEW JERSEY

Paramus Service Center Randolph Service Center Riverdale Service Center

300 Forest Avenue 1579 Sussex Tpke 95 Newark Pompton Tpke
Paramus, NJ 07652 Randolph, NJ 07869 Riverdale, NJ 07457
201-967-8100 973-927-7722 973-248-8200
Fax 201-967-7175 Fax 973-927-7683 Fax 973-248-8050

Square Dance Registration Form and Permission Slip

Please Print

Scout’s Name:___________________________________________________ Troop #:___________________________

Address:____________________________________________________________________________________________________

Home Phone #: _________________________

My daughter/ward, ,
has permission to participate in the Annual Girl Scout Square Dance at Eisenhower Middle School
1.  She is in good health and can participate without any accommodations.
2. She can participate with reasonable accommodations in respect to health or physical special needs.
List special needs
3. If I cannot be reached in the event of an emergency, the following person is authorized to act on my behalf.
Name and address
Relationship to participant Phone
Physician’s Name Phone

Emergency Medical Care Authorization: In the event of an emergency, I give my consent for emergency medical
treatment as is deemed necessary. I understand that this authority will be exercised only if reasonable attempts to
contact me should fail. I authorize (adults) Sue Moffa or Carolyn Paulson to act on my behalf to select and
authorize a physician or a hospital to give emergency care.
5. I consent that my daughter/ward may be photographed, video taped, and/or recorded and the images/recordings may
be made public in newspapers, TV, radio, Internet or other media.  Yes No

(Parent/Guardian Signature) (Date)

SQUARE DANCE FEE

The $8.00 per person donation covers admission to the Girl Scout Square Dance and fun patch.. Please make check payable your troop.
Send completed registration forms to your troop leader by November 74th

# Tickets ______________________________ Check # ________________________________

MUST BE COMPLETED AND RETURNED TO LEADER PRIOR TO PARTICIPATION

GSNNJ Forms\Permission Slip.doc 10/2008