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GIRL SCOUT VOLUNTEER CAROUSEL - Saturday, October 20, 2012

Make checks payable to GSCCS and mail registration to: Girl Scouts of Central California South, 1377 W Shaw, Fresno, CA 93711 Please print clearly (your name tag is based on our ability to read this form) and fill out completely both pages (so we can contact you if needed).
Name: (for name tag) Address: Day Phone: Email Address: City: Other Phone: Service Unit: Troop: Zip:

 The program is divided into four sessions during the event. We will attempt to give people their preferred choices, it is not always
possible so we ask that you also indicate some alternatives below in the following way. Number your most desired choices from 1 to 3 for EACH session.  Workshops are assigned on a first come first serve basis.  Plan to have lunch on site - you can bring your own or order one for $5.00. Lunch registration is due by October 9, 2012. Session 1: Number your choices 1 to 3 101 Games 102 Girl Scout History – 100 years 103 Home Scientist 104 Letterboxing 105 Paper Making 106 Silly Holidays 107 Sing Something Simple 108 T-Shirt Dyeing a Different Way 109 Girl Scouts Celebrating Cultural Session 2: Number your choices 1 to 3 201 Bugs 202 Celebrate the Holidays 203 Geocaching 204 Girl Scout World Centers 205 Porch Pals - Bugs 206 Silver & Gold Awards 207 Survivor 208 SWAPS 101 209 A Froggin’ We Will Go

Session 3: Number your choices 1 to 3 301 Bronze Award 302 Ceremonies 303 Fingerprint Art 304 Porch Pals - Farm 305 Polymer Clay 306 Take Action 307 Take a Junior Journey 308 Thank You! Thank You! 309 Recycle Clothing Session 4: Number your choices 1 to 3 401 Basic Photography 402 I’ve Been Trained…Now What Do I Do 403 Let It Snow 404 Macramé Jewelry 405 Native American Heritage 406 Nature in a Nut Shell 407 Porch Pal - Halloween 408 Making Music 409 Today’s Technology 410 Taking a Cadette Journey

Please indicate your selections:  $15.00 Morning or Afternoon only  $20.00 All day without lunch  $25.00 All day with lunch (due by Tuesday 10/9/2012)

   Complete the Health History on the back too!               

YEARLY GIRL/ADULT HEALTH HISTORY
Name (Address) (City) (State) (Evening Phone) Age (If minor)

(Day Phone) Are there any physical limitations that should be known?

History of any of the following illnesses or allergies. Check all that apply. ___Asthma ___Kidney Trouble ___Plant Allergies* ___Special Diet ___Fainting ___Epilepsy ___Sleep disturbances ___Convulsions ___Food Allergies* ___Rheumatic ___ Fever ___Heart Trouble ___Insect Bite Allergies* ___Nose Bleeds ___Sinus Infection ___Constipation ___Bed Wetting ___Medication Allergies* ___Menstrual Cramps ___Motion sickness ___Diabetes ___Emotional disturbances ___Hearing Impairment ___Other, please list* *Please specify and indicate how to treat reaction Immunization History Year Series Completed Year of Last Booster D.T.P. ____________________ __________________ Diphtheria ,Pertussis (whooping cough), Tetanus Td ____________________ ___________________ Measles ____________________ ___________________ Mumps ____________________ ___________________ Rubella ____________________ ___________________ Oral Polio ____________________ ___________________ Hib ____________________ ___________________ Tuberculin test (most recent) ____________________ (Result)___________________ Date of last tetanus injection __________ Date of Last Medical Examination ___________________ Any medication taken to camp or on troop events must be checked with the nurse or first aide and all instructions fully explained and signed by parents. NO medications can be given without written permission from parent or guardian. List any medication that you will be bringing with you to an event. Medications brought to an event should include full instructions for use. Wear glasses or contact lenses wear braces

If an emergency should arise which requires immediate medical attention, and I/guardians are unable to give my consent or my nearest relative cannot be contacted, you are authorized to initiate whatever steps are needed to protect my/my child’s health. Signed Nearest relative to contact in case of an emergency Address Emergency contact, if nearest relative is not available Address Name of Physician or Clinic Relationship Phone Phone Relationship Phone Date

Personal Medical Insurance Policy The Girl Scouts of Central California South carries group accident insurance with Mutual of Omaha for all registered girls and adults.