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Girl Scouts Louisiana East 2015 Resident Camp GIRL P WER. Get Your Camp Covington – Camp Marydale Camp Whispering Pines
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Girl Scouts Louisiana East2015 Resident Camp
GIRL P WER.
Get Your
Camp Covington – Camp MarydaleCamp Whispering Pines
Camp Marydale • Camp Whispering Pines
JOIN US AT 2015 CAMP OPEN HOUSEOpen to Girls in Grades K-12 and their families
Saturday, March 7, 2015Camp Covington Covington, LA
Sunday, March 1, 2015Sunday, March 8, 2015Camp Marydale St. Francisville, LA
Sunday, March 15, 2015Sunday, March 29, 2015Camp Whispering PinesIndependence, LA
ALL Open Houses are from 12-2 p.m.
The camp open house provides an opportunity for the girl(s) and her parents/guardians to explore camp, visit the camp sites, and receive information before camp begins. Please remember that exploring camp means walking. Wear comfortable closed toed shoes and casual clothing. This is your chance to explore camp. No need to register; come and visit us.
Turn in a completed registration form and camp deposit at any of our Open Houses, and receive $10 off your camp balance!
Resident Camp2015!We believe in the power of girls! At Resident Camp this
summer, your Girl Scout will soar to new heights as she
discovers exciting activities with brand new friends,
challenges her limits with supportive adults by her side,
and makes memories for a lifetime. You’ll be amazed at
the skills and confidence she brings home. Fun is right
around the corner!
Whether it’s hiking,
horses, or water
sports she loves, Girl
Scouts Louisiana East
has just the camp for
your girl! No matter
what program she
chooses, your girl will
enjoy swimming, boating, outdoor cooking, the beauty of
nature, and so much more! She’ll learn new skills, as she
revels in the joy of being outside, active, with friends she’s
made along the way!
2
GIRL P WER.Get Your
SUNDAYCheck-in, settle in, and meet new friends, discuss week’s activities. 6 p.m. Dinner followed by “Welcome to Camp!” and s’mores!
MONDAY-THURSDAY 7:45 a.m. Flag Ceremony/Breakfast 9 a.m. - 12 noon Activities12:30 - 1:45 p.m. Lunch/Turtle Time (rest time) 2 - 5 p.m. Activities 5:45 p.m. Flag/Dinner 7 - 9 p.m. Evening Activities 10 p.m. Showers/Bed - Lights Out
TUESDAY, BREAKFAST COOK OUT!
WEDNESDAY, DINNER COOK OUT!
FRIDAY •Packup,kapers(campchores). •Lunch •Scheduledactivity •Checkout—Seeyounextsummer!
* Girls have the option to swim every day (weather permitting)
Evening activities during the week include:SUNDAYWelcome to camp and s’mores!
MONDAYAll camp game (Capture the Flag, Camper-Counselor Scavenger Hunt, Gold Rush, etc.)
TUESDAY Girls Rock! Event (Music, Dancing, Snacks, etc.)
WEDNESDAYFollowing the cook out, units may choose a night swim, star gazing, night hike, dance, camp out, crafts, special activity, or just hanging out.
THURSDAYClosing camp fire
FRIDAYTraveling home and sharing your new experiences.
3
1-3 LOVE, HUG & PAINT $180 MDLHP1 May 31-June 2 (Sun-Tue) MD
1-3 LOVE, HUG & PAINT $180 MDLHP2 June 3-5 (Wed-Fri) MD
1-3 LOVE, HUG & PAINT $180 MDLHP3 July 5-7 (Sun-Tue) MD
1-3 LOVE, HUG & PAINT $180 MDLHP4 July 8-10 (Wed-Fri) MD
1-3 S’MORES $175 MDSM01 May 31-June 2 (Sun-Tue) MD
1-3 S’MORES $175 MDSM02 June 3-5 (Wed-Fri) MD
1-3 S’MORES $175 MDSM03 July 5-7 (Sun-Tue) MD
1-3 S’MORES $175 MDSM04 July 8-10 (Wed-Fri) MD
1-3 GIRLS ROCK $275 MDGR01 June 7-12 MD
1-3 GIRLS ROCK $275 MDGR02 June 21-26 MD
1-3 TADPOLES $175 MDTP01 June 28-30 (Sun-Tue) MD
1-3 TADPOLES $175 MDTP02 July 12-14 (Sun-Tue) MD
1-3 TADPOLES $175 MDTP03 July 15-17 (Wed-Fri) MD
1-6 SAFARI GIRLS **NEW** $150 CCSG01 June 7-9 (Sun-Tue) CC
1-6 SAFARI GIRLS **NEW** $150 CCSG02 June 14-16 (Sun-Tue) CC
1-6 DYNAMIC DUO **NEW** $150 CCDD01 June 10-12 (Wed-Fri) CC
1-6 DYNAMIC DUO **NEW** $150 CCDD02 June 17-19 (Wed-Fri) CC
1-3 SHE & ME **NEW** $150 MDSM11 June 28-July 1 (Sun-Wed) MD
4-12 SHE & ME **NEW** $150 MDSM41 June 28-July 1 (Sun-Wed) MD
1-3 SHE & ME $150 WPSM11 June 28-July 1 (Sun-Wed) WP
4-12 SHE & ME $150 WPSM41 June 28-July 1 (Sun-Wed) WP
2-3 MARYDALE MERMAIDS $275 MDMM01 June 7-12 MD
2-3 MARYDALE MERMAIDS $275 MDMM02 June 14-19 MD
2-3 MARYDALE MERMAIDS $275 MDMM03 June 21-26 MD
3-4 PONY UP $280 MDPU01 May 31-June 5 MD
3-4 PONY UP $280 MDPU02 June 14-19 MD
3-4 PONY UP $280 MDPU03 July 12-17 MD
4-6 ART-RAGEOUS $275 WPAR01 July 5-10 WP
4-6 CAMPING DIVAS $275 MDCD01 July 5-10 MD
4-6 CAMPING DIVAS $275 MDCD02 July 12-17 MD
4-6 CWP SAMPLER $175 WPSA01 June 7-9 (Sun-Tue) WP
4-6 CWP SAMPLER $175 WPSA02 June 10-12 (Wed-Fri) WP
4-6 CWP SAMPLER $175 WPSA03 June 21-23 (Sun-Tue) WP
4-6 CWP SAMPLER $175 WPSA04 June 24-26 (Wed-Fri) WP
4-6 CRAFTY CRITTERS $275 MDCC01 May 31-June 5 MD
4-6 CRAFTY CRITTERS $275 MDCC02 June 7-12 MD
4-6 COWGIRLS $325 MDCG01 May 31-June 5 MD
4-6 COWGIRLS $325 MDCG02 June 7-12 MD
4-6 COWGIRLS $325 MDCG03 June 14-19 MD
4-6 COWGIRLS $325 MDCG04 June 21-26 MD
4-6 COWGIRLS $325 MDCG05 July 5-10 MD
4-6 FIRE FLIES $275 MDFF01 July 12-17 MD
4-6 GSI-GIRL SCOUT INVESTIGATORS $275 MDGSI1 June 14-19 MD
GRA
DE
PRO
GRA
M
COST
CODE
DATE
S
Girl Scout Camp Sessions AT-A-GLANCE
4
CC = CAMP COVINGTON MD = CAMP MARYDALE WP = CAMP WHISPERING PINES
WEE
K 1
5/31
-6/5
WEE
K 2
6/7-
6/1
2
WEE
K 3
6/14
-6/1
9
WEE
K 4
6/21
-6/2
6
WEE
K 5
6/28
-7/1
WEE
K 6
7/5-
7/10
WEE
K 7
7/12
-7/1
7
GRA
DE
PRO
GRA
M
COST
CODE
DATE
S
Girl Scout Camp Sessions AT-A-GLANCE
4-6 MANE-LY HORSES $250 MDMH01 June 7-9 (Sun-Tue) MD
4-6 MANE-LY HORSES $250 MDMH02 June 10-12 (Wed-Fri) MD
4-6 PICTURE THAT $300 MDPT01 June 21-26 MD
4-6 PICTURE THAT $300 MDPT02 July 5-10 MD
4-6 SUMMER SPLASH $275 WPSS01 June 7-12 WP
4-6 SUMMER SPLASH $275 WPSS02 June 21-26 WP
4-6 SUMMER SPLASH $275 WPSS03 July 5-10 WP
6-8 BOOTS AND BRIDLES $325 MDBB01 May 31-June 5 MD
6-8 BOOTS AND BRIDLES $325 MDBB02 June 21-26 MD
6-8 GIRL SCOUT SURVIVORS $375 MDGSS1 June 21-July 1 (2 weeks) MD MD
6-8 STAR GAZERS $375 MDGS01 June 21-July 1 (2 weeks) MD MD
6-8 SADDLE UP $325 MDSU46 July 12-17 MDAGES 11-13 SPUR IN TRAINING $175 MDSIT1 June 7-12 MDAGES 11-13 SPUR IN TRAINING $175 MDSIT2 June 14-19 MDAGES 11-13 SPUR IN TRAINING $175 MDSIT3 July 12-17 MD
6-10 THRILL SEEKERS $300 WPTS01 June 7-12 WP
6-10 THRILL SEEKERS $300 WPTS02 June 21-26 WP
7-10 NIGHT RIDERS $300 MDNR01 July 5-10 MD
7-12 ALL ABOARD $300 WPAA01 July 5-10 WP
8-12 TRAIL BLAZERS $225 MDTB01 June 28-July 1 MD
9-12 BARN AIDE $100 MDBA01 May 31-June 5 MD
9-12 BARN AIDE $100 MDBA02 June 7-12 MD
9-12 BARN AIDE $100 MDBA03 June 14-19 MD
9-12 BARN AIDE $100 MDBA04 June 21-26 MD
9-12 BARN AIDE $75 MDBA05 June 28-July 1 MD
9-12 BARN AIDE $100 MDBA06 July 5-10 MD
9-12 BARN AIDE $100 MDBA07 July 12-17 MD
9-12 WRANGLER IN TRAINING I $150 MDWIT1 May 31-June 5 MD
9-12 WRANGLER IN TRAINING II $275 MDWIT2 June 7-19 (2 weeks) MD MD
10-12 COUNSELOR IN TRAINING I $125 WPC141 June 7-12 WP
10-12 COUNSELOR IN TRAINING I $125 MDC142 June 21-26 MD
10-12 COUNSELOR IN TRAINING II $125 WPC243 June 21-26 WP
10-12 COUNSELOR IN TRAINING II $225 MDC244 July 5-17 (2 weeks) MD MD
10-12 PROGRAM AIDE $100 MDPA01 May 31-June 5 MD
10-12 PROGRAM AIDE $100 MDPA02 June 7-12 MD
10-12 PROGRAM AIDE $100 MDPA03 June 14-19 MD
10-12 PROGRAM AIDE $100 MDPA04 June 21-26 MD
10-12 PROGRAM AIDE $75 MDPA05 June 28-July 1 MD
10-12 PROGRAM AIDE $100 MDPA06 July 5-10 MD
10-12 PROGRAM AIDE $100 MDPA07 July 12-17 MD
10-12 PROGRAM AIDE $100 WPPA01 June 7-12 WP
10-12 PROGRAM AIDE $100 WPPA02 June 21-26 WP
10-12 PROGRAM AIDE $75 WPPA03 June 28-July 1 WP
10-12 PROGRAM AIDE $100 MDPA04 July 5-10 WP
5
CC = CAMP COVINGTON MD = CAMP MARYDALE WP = CAMP WHISPERING PINES
WEE
K 1
5/31
-6/5
WEE
K 2
6/7-
6/1
2
WEE
K 3
6/14
-6/1
9
WEE
K 4
6/21
-6/2
6
WEE
K 5
6/28
-7/1
WEE
K 6
7/5-
7/10
WEE
K 7
7/12
-7/1
7
entering GRADES 1, 2, & 3
love, hug & paint In this mini session learn what it takes to be a true cowgirl! You will visit the barn each day where you may take a pony ride, paint a horse, or even feed them a carrot or two. When you aren’t at the barn, you’ll get to do other typical camp activities, like swimming and arts and crafts! *This session does not include archery. **Check-in 2 p.m. Sunday, check-out 5 p.m. Tuesday; or Check-in 9 a.m. Wednesday, check-out 3 p.m. Friday.** at CAMP MARYDALE, $180DATE CODEMay 31-June 2 (Sun-Tues) MDLHP1 June 3-5 (Wed-Fri) MDLHP2July 5-7 (Sun-Tues) MDLHP3July 8-10 (Wed-Fri) MDLHP4
s’mores Want to try out summer camp? Not quite ready to spend a whole week at camp? This session is for YOU! In this camp-tastic session you will discover all that camp has to offer. Take a dip in the pool, hike on a trail, make some nifty arts and crafts, and, of course, make S’MORES! *This session does not include archery. **Check-in 2 p.m. Sunday, check-out 5 p.m. Tuesday; or Check-in 9 a.m. Wednesday, check-out 3 p.m. Friday.** at CAMP MARYDALE, $175DATE CODEMay 31-June 2 (Sun-Tues) MDSM01June 3-5 (Wed-Fri) MDSM02July 5-7 (Sun-Tues) MDSM03July 8-10 (Wed-Fri) MDSM04
girls rock Inthiscampsession,you’llspendyourtimeexploringcampprograms.Plantogoonahike,roastmarshmallows, take a dip in the pool, and paddle around the lake, accompanied by older campers. *This session does not include archery. at CAMP MARYDALE, $275DATE CODEJune 7-12 MDGR01June 21-26 MDSM02
tadpoles Come to this three-day session to dip your toes in the water! Not a strong swimmer? Take your first stroke to becoming a more confident swimmer by participating in water games and activities. In your spare time, you will experience other typical camp activities. *This session does not include archery. **Check-in 2 p.m. Sunday, check-out 5 p.m. Tuesday; or Check-in 9 a.m. Wednesday, check-out 3 p.m. Friday.** at CAMP MARYDALE, $175DATE CODEJune 28-30 (Sun-Tues) MDTP01July 12-14 (Sun-Tues) MDTP02July 15-17 (Wed-Fri) MDTP03
6
entering GRADES 1 through 6
SAFARI GIRLS **new** Come spend three days at camp with the woman you admire most! Go on a trust hike together, make jewlery, and take a dip in the river! You will enjoy many other activities like team building and outdoor cooking. You and your duo will even take a trip to the near-by Global Wildlife and go on a safari! This is a staff-led event in which “campers” (adults and girls) will follow the lead of their counselors (council camp staff) throughout the entire day. Limit: each girl may bring one female adult. Activities depend on the camper’s grade level. Duos are responsible for their own transportation to Global Wildlife Center. **Check-in 2 p.m. Sunday. Check-out 5 p.m. Tuesday.** at CAMP COVINGTON, $150/personDATE CODEJune 7-9 (Sun-Tues) CCSG01June 14-16 (Sun-Tues) CCSG02
DYNAMIC DUO **new** Enjoy three days at camp with the fella you admire most! Your duo will go on a trust hike together, build a craft, and take a dip in the river! One of the days, you will even go on a field trip! You will enjoy many other activities like team building and outdoor cooking. This is a staff-led event in which “campers” (adults and girls) will follow the lead of their counselors (council camp staff) throughout the entire day. Limit: each girl may bring one appropriate male adult. Activities depend on the camper’s grade level. **Check-in 9 a.m. Wednesday. Check-out 3 p.m. Friday.** at CAMP COVINGTON, $150/personDATE CODEJune 10-12 (Wed-Fri) CCDD01June 17-19 (Wed-Fri) CCDD02
entering GRADES 1 through 12
she & me **new** Four, fun days are in store for you and the woman you admire most! Go on a trust hike together, make jewlery, and canoe around the lake! You will enjoy many other activities like archery, swimming, and the high ropes course. This is a staff-led event in which “campers” (adults and girls) will follow the lead of their counselors (council camp staff) throughout the entire day. Limit: each girl may bring one female adult. Activities depend on the camper’s grade level. **Check-in 2 p.m. Sunday. Check-out 3 p.m. Wednesday.** at CAMP Marydale, $150/personDATE GRADES CODEJune 28-July 1 (Sun-Wed) 1-3 MDSM11June 28-July 1 (Sun-Wed) 4-12 MDSM41
she & me Come spend four days at camp with the woman you admire most! Go on a trust hike together, make jewlery, and canoe around the lake! You will enjoy many other activities like archery, swimming, and the high ropes course. This is a staff-led event in which “campers” (adults and girls) will follow the lead of their counselors (council camp staff) throughout the entire day. Limit: each girl may bring one female adult. Activities depend on the camper’s grade level. **Check-in 2 p.m. Sunday. Check-out 3 p.m. Wednesday.** at CAMP WHISPERING PINES, $150/personDATE GRADES CODEJune 28-July 1 (Sun-Wed) 1-3 WPSM11June 28-July 1 (Sun-Wed) 4-12 WPSM41
7
entering GRADES 2 & 3
marydale mermaids Take your swimming skills to the next level! Learn basic water safety, improve on your swimming techniques, play water games, and just enjoy splishin’ and splashin’ all week long! *This session does not include archery. at CAMP MARYDALE, $275DATE CODEJune 7-12 MDMM01June 14-19 MDMM02June 21-26 MDMM03
entering GRADES 3 & 4
pony up Still trying to figure out where you fit in the horse world? No problem! This progressive equine session is just what you need. Begin the week with a pony ride to get the feel of horses. Throughout the week you will grow by learning about ground safety, grooming, leading, and feeding! If you feel up to it at the end of the week, you’ll ride your horse all by yourself! **Campers in this session do not ride horses each day, but will work hands-on with them daily in order to become comfortable.** at CAMP MARYDALE, $280 DATE CODEMay 31-June 5 MDPU01June 14-19 MDPU02July 12-17 MDPU03
entering GRADES 4, 5, & 6
art-rageous ACampWhisperingPinesfavoriteisArt-Rageous!Enjoymakingjewlery,playingwithclay,tie-dying,and painting! When you’re not crafting, you’ll enjoy typical camp activities such as swimming, hiking, and canoeing. at CAMP WHISPERING PINES, $275 DATE CODEJuly 5-10 WPAR01
camping divas Does your heart love the outdoors but your body love pampering? This week, you’ll host a dance party (Bring your party planning ideas!), make your own lip gloss, make a no-sew pillow case, attend a water aerobics class, and learn yoga! In your spare time, you’ll get to enjoy other typical camp activities! at CAMP MARYDALE, $275DATE CODEJuly 5-10 MDCD01July 12-17 MDCD02
8
MA
IL REG
ISTRA
TION
FOR
MS TO
: G
irl Scouts Louisiana East P
LEA
SE
PR
INT C
LEA
RLY
545 Colonial D
rive w
ww
.gsle.org Front &
Back Form
B
aton Rouge, LA
70806
OV
ER
à
Resident C
amp R
egistration Form
• Include $50 non-refundable deposit per session.
• M
ail to address listed above or fax with credit card inform
ation to (225) 927-8402. •
A separate registration form
and deposit is required for each camper.
• R
egistration form m
ust be filled out completely to be processed.
• O
ne camper and one session per form
.
CA
MPER
INFO
RM
ATIO
N
Cam
per’s Full Nam
e _____________________________________________________________________________________
Address ___________________________________________________ P
arish _____________________________________
City _____________________________________ S
tate_____ Zip____________ Age______ D
ate of Birth ________________
Registered G
irl Scout (check one)
q Y
es q
No G
rade entering in Fall _______ Troop # ________
______________________________ (______)__________________ (______)_________________ ________________________________ P
arent/Guardian
Day
Cell
Em
ail
______________________________ (______)__________________ (______)_________________ ________________________________ P
arent/Guardian
Day
Cell
Em
ail
This camper is in the custodial care of ______________________________________________________________________
BU
DD
Y INFO
RM
ATIO
N
Nam
e of girl(s) your camper w
ould like to have in the same cabin. C
ampers m
ust request each other and submit form
s by walk-in or by m
ail in the sam
e envelope. Placem
ent cannot be guaranteed.
Buddy N
ame(s) _________________________________________________________________________________
RESID
ENT C
AM
P PRO
GR
AM
/CO
DE
1st Choice _____________________________________________________________ _________________________________
Program
Nam
e
C
ode 2nd C
hoice ____________________________________________________________ _________________________________ P
rogram N
ame
Code
T-shirt size: q
YS
q Y
M q
YL q
AS
q A
M q
AL q
AX
L q A
XX
L C
amp Fee C
hecklist Am
ount
Session Fee
(Total balance is due 3 weeks prior to cam
p session.) $
*Mem
bership R
egistration Fee
IF NOT currently a registered G
irl Scout, please include $15 Girl Scout M
embership fee. Please register m
y cam
per as a Girl Scout for the 2015 m
embership year.
Parent/Guardian Signature ___________________________________________
$
SUB
-TOTA
L Total C
amp Fees
$
Deposit(s) D
ue w
ith this form
$50 non-‐refundable deposit *must be included w
ith this form.
Payable with Cash, Credit Card, Check or Santa’s certificate(s).
– $ 50.00*
You have the option to pay an additional am
ount towards your balance, please indicate it in the box to the right.
D
UE three w
eeks prior to your camper’s session. —
Total Balance D
ue $
Check m
ethod of payment:
q C
ash q M
astercard q V
isa q D
iscover q A
ME
X
q D
ebit q C
heck q M
oney Order
q S
anta’s Certificate(s) m
ust be enclosed with this form
. Am
t. $______
Credit C
ard Num
ber:
____________ – ____________ – ____________ – ____________
Expiration D
ate: ______________________
Print C
ardholder’s Nam
e X
______________________________________________________
Cardholder’s Signature
X ____________________________________________________
o
Check here if requesting C
amp Scholarship
Attach C
amp Scholarship application to this registration. (A
pplication are DU
E by March 15, 2015)
CHECK how
you want the
confirmation packet sent to you.
q Em
ail q Postm
aster
One
For
m a
nd O
ne D
epos
it P
er S
essi
on P
er G
irl —
May
be
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toco
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BA
CK
GS
LE 1
1/14
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t Cam
p R
egis
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ion
cont
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MIS
SIO
N:
I am
enc
losi
ng th
e no
n-re
fund
able
$50
dep
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(per
ses
sion
). I a
lso
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rsta
nd th
e ba
lanc
e of
rem
aind
er o
f the
cam
p fe
e is
due
th
ree
wee
ks p
rior t
o ca
mp
sess
ion.
I u
nder
stan
d if
my
child
has
requ
este
d a
Cam
p B
uddy
, ALL
regi
stra
tions
and
dep
osits
mus
t be
rece
ived
at t
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ounc
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fice
in
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and
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ill b
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Cam
pers
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ned
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fo
r my
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’s c
amp
sess
ion.
__
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
__
Par
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uard
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natu
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Dat
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ctio
ns o
f cou
nsel
ors,
use
the
budd
y sy
stem
, and
sta
y w
ithin
cam
p bo
unda
ries.
No
drug
s, a
lcoh
ol, p
ets,
or w
eapo
ns a
re p
erm
itted
on
cam
p pr
oper
ty. T
he c
amp
dire
ctor
rese
rves
the
right
to s
end
hom
e an
y ca
mpe
r who
neg
lect
s to
follo
w c
amp
rule
s, b
ecom
es a
dan
ger t
o he
rsel
f and
/or
othe
rs, o
r dam
ages
pro
perty
. No
refu
nd w
ill b
e gi
ven
if a
child
is s
ent h
ome
due
to m
isco
nduc
t. C
ELL
PHO
NE
AG
REE
MEN
T •
I und
erst
and
that
cel
l pho
nes
are
not a
ppro
pria
te a
t cam
p an
d I a
gree
to le
ave
my
cell
phon
e at
hom
e.
• I a
lso
unde
rsta
nd th
at if
I br
eak
this
rule
and
I am
foun
d w
ith a
cel
l pho
ne, t
he C
amp
Dire
ctor
will
hol
d ph
one
until
ch
ecko
ut.
• Th
e ca
mp
and
cam
p di
rect
or a
re n
ot re
spon
sibl
e fo
r los
t or d
amag
ed c
ell p
hone
s.
• I a
gree
to s
peak
to m
y un
it co
unse
lor i
n th
e ev
ent o
f an
emer
genc
y, h
omes
ickn
ess,
etc
. so
that
my
need
s ca
n be
ad
dres
sed.
__
____
____
____
____
____
____
____
____
____
____
____
____
____
_
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Par
ent/G
uard
ian
Sig
natu
re
D
ate
Cam
per S
igna
ture
D
ate
____
____
____
____
____
____
____
____
____
____
____
____
____
__
___
____
____
____
____
____
____
____
____
____
____
____
____
____
P
rint N
ame
of P
aren
t/Gua
rdia
n
Prin
t Nam
e of
Cam
per
EMER
GEN
CY
CO
NTA
CT
(if p
aren
t/gua
rdia
n ca
nnot
be
reac
hed)
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
___
____
____
____
____
____
____
____
____
____
_ N
ame
R
elat
ion
to C
ampe
r
(___
____
_)__
____
____
____
____
____
____
___
(___
____
_)__
____
____
____
____
____
____
___
(___
____
_)__
____
____
____
____
____
____
_ H
ome
W
ork
C
ell
RA
CIA
L B
AC
KG
RO
UN
D
q A
mer
ican
Indi
an, A
lask
an N
ativ
e q
Asi
an
q B
lack
, Afri
can
Am
eric
an
q H
awai
ian,
Pac
ific
Isla
nder
q
Whi
te q
Oth
er
ETH
NIC
BA
CK
GR
OU
ND
q
His
pani
c or
Lat
ina
q N
ot H
ispa
nic
or L
atin
a
q P
leas
e ch
eck
if yo
ur c
hild
nee
ds s
peci
al a
ssis
tanc
e, i.
e. d
ieta
ry, m
obili
ty, i
nter
pret
er, e
tc. W
e w
ill m
ake
ever
y ef
fort
to
acc
omm
odat
e al
l girl
s w
here
pos
sibl
e. P
leas
e ex
plai
n.
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Make your doctor’s appointment today for your physical examination.
Health Exam
ination:D
ate of examination ________________________________________
Height _______________ W
eight ______________ B.P. ____________A
ppearance – Nutrition _____________________________________
W
ithout Glasses
With G
lassesEyes R 20/ ________ L 20/________ R 20/ _______ L 20/ _________Ears ______________________________ H
earing R ____________
L____________Code:
Satisfactory ✔
Not Satisfactory ✗
N
ot Examined W
Nose______________________________________________________
Throat ____________________________________________________Teeth _____________________________________________________H
eart _____________________________________________________Lungs _____________________________________________________A
bdomen _________________________________________________
Genitalia __________________________________________________
Hernia ____________________________________________________
Skin ______________________________________________________M
usculoskeletal ____________________________________________G
eneral physical and emotional status ________________________
Urinalysis* _______________________ H
GB* ____________________
Other notes________________________________________________
____________________________________________________________________________________________________________________
* Not required for every health exam
ination. A G
irl Scout Daisy, Brow
nie, or Junior should have the test if she has not already had it, either w
hen entering school or at any tim
e since. A G
irl Scout Cadette, Senior or Am
bassador should have this test if she has not had it since entering puberty.**Adult tetanus-diphtheria toxoid*** H
aemophilus influenza b
Record of Imm
unizations:Im
munization
Year Primary
Year Of
Series Com
pleted Last Booster
D.T.P.
________________ ________________
Diphtheria
________________
Pertussis (Whooping Cough)
________________ Tetanus
________________
Td** ________________
________________O
ral polio ________________
________________M
easles ________________
________________M
umps
________________ ________________
Hib***
Hbpv***
________________ ________________
Tuberculin test Type ___________
________________
Year last given ____________________________
Result ___________________________________O
ther ________________
________________
Physician’ s comm
ents and recomm
endationsG
ive details or indicate managem
ent of significant illnesses.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
This person is in satisfactory condition and may engage in all usual activities
except as noted.Licensed physician’ s nam
e _________________________________________
Licensed physician’ s signature______________________________________
Address ________________________________________________________
City_______________________________ State _______ Zip _____________
Phone (_________)___________________________ Date _____________
THIS PO
RTION
TO BE fIllEd
In by pH
ysICIan
AfTER REvIEW
Of H
EALTH
HISTO
RY WITH
paREn
t/gu
aRd
Ian
.
gIRl H
EaltH
EXaM
InatIO
n RECO
RdTH
IS PORTIO
N TO
BE fIllEd In
by paREn
t AN
D REvIEW
ED W
ITH PH
YSICIAN
AT THE TIM
E Of ExA
MIN
ATION
Nam
e (Last, first, Initial) Parent or G
uardian (A
rea Code) Phone
Address City or Tow
n State
Zip Code D
ate of Birth Age
Sex
In Emergency N
otifyAddress
(Area Code) Phone
Health H
istory: (Check those that apply)
❑
Chicken Pox
❑ M
easles
❑ G
erman M
easles
❑ M
umps
allergies
❑
Anim
als
❑ food
❑
Hay fever
❑
Insect Stings
❑ M
edicine/Drugs
❑
Plants
❑ Pollen
❑
Other
Chronic or Recurring Illnesses
❑ A
DD
/AD
HD
❑ A
sthma
❑
Bleeding Disorders
❑
Diabetes
❑
Ear Infections
❑ H
eart Defect/D
isease
❑ H
ypertension
❑ M
usculoskeletal Disorders
❑
Seizures
❑ O
ther (Specify)__________CO
MM
Ents W
HERE a
pplICablE:
Operations or serious injuries _________________________________________________
Hospitalizations _____________________________________________________________
Other diseases/disabilities ____________________________________________________
suggestions from parent:
pROg
RaM
attEnd
Ing
datE attEn
dIn
g
COM
MEn
ts WH
ERE applICa
blE:fainting ___________________________________________________ Sleep D
isturbances _________________________________________Bed w
etting________________________________________________ Menstrual cram
ps __________________________________________Constipation _______________________________________________ N
osebleeds ________________________________________________Em
otional disturbances _____________________________________ Other _____________________________________________________
Specific activities to be encouraged _________________________________________________________________________________________restricted _______________________________________________________________________________________________________
Special medical or dietary regim
en to be followed (specify) ____________________________________________________________
This health history is correct and my daughter has perm
ission to engage in all prescribed activities, except as noted by me and the exam
ining physician.Signature of Parent/G
uardian _________________________________________________________________ Date _______________________
UD
: 02/2011
Hea
lth
Exam
inat
ion:
Dat
e of
exa
min
atio
n __
____
____
____
____
____
____
____
____
____
__H
eigh
t ___
____
____
____
Wei
ght _
____
____
____
_ B.
P. _
____
____
___
App
eara
nce
– N
utrit
ion
____
____
____
____
____
____
____
____
____
_
With
out G
lass
es
With
Gla
sses
Eyes
R 2
0/ _
____
___
L 2
0/__
____
__
R 20
/ ___
____
L 2
0/ _
____
____
Ears
___
____
____
____
____
____
____
___
H
earin
g
R __
____
____
__
L
____
____
____
Code
: Sa
tisfa
ctor
y ✔
N
ot S
atis
fact
ory ✗
N
ot E
xam
ined
WN
ose_
____
____
____
____
____
____
____
____
____
____
____
____
____
_Th
roat
___
____
____
____
____
____
____
____
____
____
____
____
____
_Te
eth
____
____
____
____
____
____
____
____
____
____
____
____
____
_H
eart
___
____
____
____
____
____
____
____
____
____
____
____
____
__Lu
ngs
____
____
____
____
____
____
____
____
____
____
____
____
____
_A
bdom
en _
____
____
____
____
____
____
____
____
____
____
____
____
Gen
italia
___
____
____
____
____
____
____
____
____
____
____
____
___
Her
nia
____
____
____
____
____
____
____
____
____
____
____
____
____
Skin
___
____
____
____
____
____
____
____
____
____
____
____
____
___
Mus
culo
skel
etal
___
____
____
____
____
____
____
____
____
____
____
_G
ener
al p
hysi
cal a
nd e
mot
iona
l sta
tus
____
____
____
____
____
____
Urin
alys
is*
____
____
____
____
____
___
HG
B* _
____
____
____
____
___
Oth
er n
otes
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
* N
ot re
quire
d fo
r eve
ry h
ealth
exa
min
atio
n. A
Girl
Sco
ut D
aisy
, Bro
wni
e, o
r Ju
nior
sho
uld
have
the
test
if s
he h
as n
ot a
lread
y ha
d it,
eith
er w
hen
ente
ring
scho
ol o
r at a
ny ti
me
sinc
e. A
Girl
Sco
ut C
adet
te, S
enio
r or A
mba
ssad
or s
houl
d ha
ve th
is te
st if
she
has
not
had
it s
ince
ent
erin
g pu
bert
y.**
Adul
t tet
anus
-dip
hthe
ria to
xoid
***
Hae
mop
hilu
s in
fluen
za b
Reco
rd o
f Im
mun
izat
ions
:Im
mun
izat
ion
Year
Prim
ary
Year
Of
Se
ries
Com
plet
ed
Last
Boo
ster
D.T
.P.
____
____
____
____
__
____
____
____
__
Dip
hthe
ria
__
____
____
____
__
Per
tuss
is (W
hoop
ing
Coug
h)
____
____
____
____
Te
tanu
s
__
____
____
____
__Td
**
____
____
____
____
__
____
____
____
__O
ral p
olio
__
____
____
____
__
____
____
____
____
Mea
sles
__
____
____
____
__
____
____
____
____
Mum
ps
____
____
____
____
__
____
____
____
__H
ib**
*H
bpv*
**
____
____
____
____
__
____
____
____
__Tu
berc
ulin
test
Ty
pe _
____
____
__
____
____
____
____
Ye
ar la
st g
iven
___
____
____
____
____
____
____
_
Resu
lt __
____
____
____
____
____
____
____
____
_O
ther
__
____
____
____
__
____
____
____
____
Phys
icia
n’ s
com
men
ts a
nd re
com
men
datio
nsG
ive
deta
ils o
r ind
icat
e m
anag
emen
t of s
igni
fican
t illn
esse
s.
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
This
per
son
is in
sat
isfa
ctor
y co
nditi
on a
nd m
ay e
ngag
e in
all
usua
l act
iviti
es
exce
pt a
s no
ted.
Lice
nsed
phy
sici
an’ s
nam
e __
____
____
____
____
____
____
____
____
____
___
Lice
nsed
phy
sici
an’ s
sig
natu
re__
____
____
____
____
____
____
____
____
____
Addr
ess
____
____
____
____
____
____
____
____
____
____
____
____
____
____
City
____
____
____
____
____
____
____
___
Stat
e __
____
_ Zi
p __
____
____
___
Phon
e (_
____
____
)___
____
____
____
____
____
____
Dat
e __
____
____
___
THIS
PO
RTIO
N T
O B
E fI
llEd
In b
y pH
ysIC
Ian
AfT
ER R
EvIE
W O
f H
EALT
H H
ISTO
RY W
ITH
pa
REn
t/g
ua
RdIa
n.
gIR
l H
Ealt
H E
XaM
Inat
IOn
REC
ORd
THIS
PO
RTIO
N T
O B
E fI
llEd
In b
y pa
REn
t A
ND
REv
IEW
ED W
ITH
PH
YSIC
IAN
AT
THE
TIM
E O
f Ex
AM
INAT
ION
Nam
e (L
ast,
firs
t, In
itial
) Pa
rent
or G
uard
ian
(Are
a Co
de) P
hone
Addr
ess
City
or T
own
Stat
e Zi
p Co
de
Dat
e of
Birt
h Ag
e Se
x
In E
mer
genc
y N
otify
Addr
ess
(Are
a Co
de) P
hone
Hea
lth
His
tory
: (Ch
eck
thos
e th
at a
pply
)
❑
Chi
cken
Pox
❑
Mea
sles
❑
Ger
man
Mea
sles
❑
Mum
ps
alle
rgie
s
❑ A
nim
als
❑
foo
d
❑ H
ay f
ever
❑
Inse
ct S
tings
❑
Med
icin
e/D
rugs
❑
Pla
nts
❑
Pol
len
❑
Oth
er
Chro
nic
or R
ecur
ring
Illn
esse
s
❑ A
DD
/AD
HD
❑ A
sthm
a
❑ B
leed
ing
Dis
orde
rs
❑ D
iabe
tes
❑
Ear
Infe
ctio
ns
❑ H
eart
Def
ect/
Dis
ease
❑
Hyp
erte
nsio
n
❑ M
uscu
losk
elet
al D
isor
ders
❑
Sei
zure
s
❑ O
ther
(Spe
cify
)___
____
___
COM
MEn
ts W
HER
E a
pplI
Cabl
E:
Ope
ratio
ns o
r ser
ious
inju
ries
____
____
____
____
____
____
____
____
____
____
____
____
_H
ospi
taliz
atio
ns _
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Oth
er d
isea
ses/
disa
bilit
ies
____
____
____
____
____
____
____
____
____
____
____
____
____
sugg
esti
ons
from
par
ent:
pRO
gRa
M a
ttEn
dIn
g
dat
E at
tEn
dIn
g
COM
MEn
ts W
HER
E a
pplI
Cabl
E:fa
intin
g __
____
____
____
____
____
____
____
____
____
____
____
____
_
Sle
ep D
istu
rban
ces
____
____
____
____
____
____
____
____
____
____
_Be
d w
ettin
g___
____
____
____
____
____
____
____
____
____
____
____
_
Men
stru
al c
ram
ps _
____
____
____
____
____
____
____
____
____
____
_Co
nstip
atio
n __
____
____
____
____
____
____
____
____
____
____
____
_
Nos
eble
eds
____
____
____
____
____
____
____
____
____
____
____
____
Emot
iona
l dis
turb
ance
s __
____
____
____
____
____
____
____
____
___
Oth
er _
____
____
____
____
____
____
____
____
____
____
____
____
____
Spec
ific
activ
ities
to b
e en
cour
aged
___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__re
stric
ted
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Spec
ial m
edic
al o
r die
tary
regi
men
to b
e fo
llow
ed (s
peci
fy) _
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
This
hea
lth h
isto
ry is
cor
rect
and
my
daug
hter
has
per
mis
sion
to e
ngag
e in
all
pres
crib
ed a
ctiv
ities
, exc
ept a
s no
ted
by m
e an
d th
e ex
amin
ing
phys
icia
n.Si
gnat
ure
of P
aren
t/G
uard
ian
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
_ D
ate
____
____
____
____
____
___
UD
: 02/
2011
9
entering GRADES 4, 5, & 6
camp whispering pines sampler In this three-day session, you will sample all that our water camp has to offer. Take a paddle around the cove, splash in the pool, and slide down the water slide! In your spare time, you’ll enjoy tie dye and hiking! **Check-in 2 p.m. Sunday; 9 a.m. Wednesday. Check-out 5 p.m. Tuesday; 3 p.m. Friday.** at CAMP WHISPERING PINES, $175 DATE CODEJune 7-9 (Sun-Tues) WPSA01June 10-12 (Wed-Fri) WPSA02June 21-23 (Sun-Tues) WPSA03June 24-26 (Wed-Fri) WPSA04
crafty critters If you enjoy making arts & crafts, this session is for you! You will learn how to make jewlery and lanyards, mold clay, and play with modge podge and plaster! When you’re not being a crafty critter, you’ll be participating in camp activities such as hiking and swimming! at CAMP MARYDALE, $275DATE CODEMay 31-June 5 MDCC01June 7-12 MDCC02
cowgirls Brush off your boots! It’s time to grab the reins and hang on tight! In this camp session you will learn the basics of horsemanship. Groom, saddle, and study the essentials of walking, trotting, and trail riding on your horse! When you aren’t playing cowgirl, you will be swimming, cooking over an open fire, and discovering all that camp has to offer! at CAMP MARYDALE, $325DATE CODEMay 31-June 5 MDCG01June 7-12 MDCG02June 14-19 MDCG03June 21-26 MDCG04July 5-10 MDCG05
fire flies Enjoy sleeping in and staying up late while experiencing all that camp has to offer. During the night, you’ll enjoy activities such as tent camping, canoeing, arts & crafts, and scavenger hunts. at CAMP MARYDALE, $275DATE CODEJuly 12-17 MDFF01
10
entering GRADES 4, 5, & 6
mane-ly horses Here is your chance to see if hanging out with Camp Marydale’s horses is for you! In this short three-day session, you will learn the basics of riding and grooming horses. Get ready for the last day because you’ll be kicking up your heels on a trail ride to test out what you’ve learned. Little or NO riding skill needed! **Check-in 2 p.m. Sunday; 9 a.m. Wednesday. Check-out 5 p.m. Tuesday; 3 p.m. Friday.** at CAMP MARYDALE, $250DATE CODEJune 7-9 (Sun-Tues) MDMH01June 10-12 (Wed-Fri) MDMH02
gsi – girl scout investigators There have been shenanigans at Camp Marydale and we need YOU to solve them! Spend your week solving different mysteries, taking scavenger hunts, and putting your brains together to create a scavenger hunt for the rest of camp! In your free time you’ll participate in other activities such as swimming and arts & crafts! at CAMP MARYDALE, $275DATE CODEJune 14-19 MDGSI1
picture that! Budding photographers, come to Marydale and learn to use your new camera (included in the session price). Meet a professional photographer and get tips on how to take fantastic pictures. You will document your summer vacation with great photos of your camp experience and your new friends. Turn those pictures into a camp keepsake scrapbook. Enjoy all the other fun camp has to offer. at CAMP MARYDALE, $300 DATE CODEJune 21-26, 2015 MDPT01July 5-10, 2015 MDPT02
summer splash! Do you love the water? Spend the week playing pool games, boating, and tubing! You’ll, of course, get to play on the Timber Lake Slide! When you’re not playing in the water, you’ll get to enjoy archery and climbing the rock wall! at CAMP WHISPERING PINES, $275DATE CODEJune 7-12 WPSS01June 21-26 WPSS02July 5-10 WPSS03
One
For
m a
nd O
ne D
epos
it P
er S
essi
on P
er G
irl —
May
be
Pho
toco
pied
BA
CK
GS
LE 1
1/14
Res
iden
t Cam
p R
egis
trat
ion
cont
inue
d PA
REN
T/G
UA
RD
IAN
PER
MIS
SIO
N:
I am
enc
losi
ng th
e no
n-re
fund
able
$50
dep
osit
(per
ses
sion
). I a
lso
unde
rsta
nd th
e ba
lanc
e of
rem
aind
er o
f the
cam
p fe
e is
due
th
ree
wee
ks p
rior t
o ca
mp
sess
ion.
I u
nder
stan
d if
my
child
has
requ
este
d a
Cam
p B
uddy
, ALL
regi
stra
tions
and
dep
osits
mus
t be
rece
ived
at t
he c
ounc
il of
fice
in
the
sam
e en
velo
pe. I
und
erst
and
ever
y at
tem
pt w
ill b
e m
ade
to h
onor
thei
r req
uest
. I u
nder
stan
d th
at m
y ca
mpe
r will
be
shar
ing
a ca
bin/
tent
with
girl
s si
mila
r in
age.
I un
ders
tand
that
an
adul
t cam
p co
unse
lor i
s in
a c
abin
nea
rby.
M
y ch
ild h
as p
erm
issi
on to
par
ticip
ate
in a
ll ph
ases
of c
amp
exce
pt a
s no
ted
on th
e C
amp
Hea
lth F
orm
, to
appe
ar in
pic
ture
s fo
r pu
blic
ity p
urpo
ses,
incl
udin
g co
unci
l web
site
and
rela
ted
orga
niza
tions
web
site
s, a
nd to
be
regi
ster
ed a
s a
Girl
Sco
ut if
she
is
pres
ently
a n
on-G
irl S
cout
. I h
ave
read
the
cam
p in
form
atio
n an
d ag
ree
to c
oope
rate
with
all
polic
ies.
Cam
pers
will
hav
e th
e op
portu
nity
to p
artic
ipat
e in
hig
h-ris
k ac
tiviti
es s
uch
as s
wim
min
g, h
orse
back
ridi
ng, c
anoe
ing
and/
or th
e ch
alle
nge
cour
se/c
limbi
ng w
all.
Alth
ough
car
e is
giv
en to
gre
atly
redu
ce th
e ris
k in
volv
ed th
roug
h sa
fety
pro
cedu
res,
edu
catio
n an
d eq
uipm
ent,
I und
erst
and
high
adv
entu
re p
rogr
ams
are
not w
ithou
t an
elem
ent o
f dan
ger.
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erst
and
the
risk
invo
lved
with
this
ty
pe o
f pro
gram
, and
I fe
el th
e be
nefit
s ou
twei
gh th
e po
tent
ial h
azar
ds o
f the
pro
gram
. My
child
has
per
mis
sion
to ta
ke p
art i
n an
d tra
vel t
o an
act
ivity
off
site
of c
amp
or b
etw
een
any
of th
e G
irl S
cout
s Lo
uisi
ana
Eas
t cam
ps a
s pa
rt of
the
plan
ned
activ
ities
fo
r my
child
’s c
amp
sess
ion.
__
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
__
Par
ent/G
uard
ian
Sig
natu
re
Dat
e EX
PEC
TED
CA
MPE
R B
EHA
VIO
R
Girl
s ar
e ex
pect
ed to
follo
w th
e G
irl S
cout
Pro
mis
e an
d La
w, l
iste
n an
d fo
llow
the
dire
ctio
ns o
f cou
nsel
ors,
use
the
budd
y sy
stem
, and
sta
y w
ithin
cam
p bo
unda
ries.
No
drug
s, a
lcoh
ol, p
ets,
or w
eapo
ns a
re p
erm
itted
on
cam
p pr
oper
ty. T
he c
amp
dire
ctor
rese
rves
the
right
to s
end
hom
e an
y ca
mpe
r who
neg
lect
s to
follo
w c
amp
rule
s, b
ecom
es a
dan
ger t
o he
rsel
f and
/or
othe
rs, o
r dam
ages
pro
perty
. No
refu
nd w
ill b
e gi
ven
if a
child
is s
ent h
ome
due
to m
isco
nduc
t. C
ELL
PHO
NE
AG
REE
MEN
T •
I und
erst
and
that
cel
l pho
nes
are
not a
ppro
pria
te a
t cam
p an
d I a
gree
to le
ave
my
cell
phon
e at
hom
e.
• I a
lso
unde
rsta
nd th
at if
I br
eak
this
rule
and
I am
foun
d w
ith a
cel
l pho
ne, t
he C
amp
Dire
ctor
will
hol
d ph
one
until
ch
ecko
ut.
• Th
e ca
mp
and
cam
p di
rect
or a
re n
ot re
spon
sibl
e fo
r los
t or d
amag
ed c
ell p
hone
s.
• I a
gree
to s
peak
to m
y un
it co
unse
lor i
n th
e ev
ent o
f an
emer
genc
y, h
omes
ickn
ess,
etc
. so
that
my
need
s ca
n be
ad
dres
sed.
__
____
____
____
____
____
____
____
____
____
____
____
____
____
_
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Par
ent/G
uard
ian
Sig
natu
re
D
ate
Cam
per S
igna
ture
D
ate
____
____
____
____
____
____
____
____
____
____
____
____
____
__
___
____
____
____
____
____
____
____
____
____
____
____
____
____
P
rint N
ame
of P
aren
t/Gua
rdia
n
Prin
t Nam
e of
Cam
per
EMER
GEN
CY
CO
NTA
CT
(if p
aren
t/gua
rdia
n ca
nnot
be
reac
hed)
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
___
____
____
____
____
____
____
____
____
____
_ N
ame
R
elat
ion
to C
ampe
r
(___
____
_)__
____
____
____
____
____
____
___
(___
____
_)__
____
____
____
____
____
____
___
(___
____
_)__
____
____
____
____
____
____
_ H
ome
W
ork
C
ell
RA
CIA
L B
AC
KG
RO
UN
D
q A
mer
ican
Indi
an, A
lask
an N
ativ
e q
Asi
an
q B
lack
, Afri
can
Am
eric
an
q H
awai
ian,
Pac
ific
Isla
nder
q
Whi
te q
Oth
er
ETH
NIC
BA
CK
GR
OU
ND
q
His
pani
c or
Lat
ina
q N
ot H
ispa
nic
or L
atin
a
q P
leas
e ch
eck
if yo
ur c
hild
nee
ds s
peci
al a
ssis
tanc
e, i.
e. d
ieta
ry, m
obili
ty, i
nter
pret
er, e
tc. W
e w
ill m
ake
ever
y ef
fort
to
acc
omm
odat
e al
l girl
s w
here
pos
sibl
e. P
leas
e ex
plai
n.
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
One
For
m a
nd O
ne D
epos
it P
er S
essi
on P
er G
irl —
May
be
Pho
toco
pied
BA
CK
GS
LE 1
1/14
Res
iden
t Cam
p R
egis
trat
ion
cont
inue
d PA
REN
T/G
UA
RD
IAN
PER
MIS
SIO
N:
I am
enc
losi
ng th
e no
n-re
fund
able
$50
dep
osit
(per
ses
sion
). I a
lso
unde
rsta
nd th
e ba
lanc
e of
rem
aind
er o
f the
cam
p fe
e is
due
th
ree
wee
ks p
rior t
o ca
mp
sess
ion.
I u
nder
stan
d if
my
child
has
requ
este
d a
Cam
p B
uddy
, ALL
regi
stra
tions
and
dep
osits
mus
t be
rece
ived
at t
he c
ounc
il of
fice
in
the
sam
e en
velo
pe. I
und
erst
and
ever
y at
tem
pt w
ill b
e m
ade
to h
onor
thei
r req
uest
. I u
nder
stan
d th
at m
y ca
mpe
r will
be
shar
ing
a ca
bin/
tent
with
girl
s si
mila
r in
age.
I un
ders
tand
that
an
adul
t cam
p co
unse
lor i
s in
a c
abin
nea
rby.
M
y ch
ild h
as p
erm
issi
on to
par
ticip
ate
in a
ll ph
ases
of c
amp
exce
pt a
s no
ted
on th
e C
amp
Hea
lth F
orm
, to
appe
ar in
pic
ture
s fo
r pu
blic
ity p
urpo
ses,
incl
udin
g co
unci
l web
site
and
rela
ted
orga
niza
tions
web
site
s, a
nd to
be
regi
ster
ed a
s a
Girl
Sco
ut if
she
is
pres
ently
a n
on-G
irl S
cout
. I h
ave
read
the
cam
p in
form
atio
n an
d ag
ree
to c
oope
rate
with
all
polic
ies.
Cam
pers
will
hav
e th
e op
portu
nity
to p
artic
ipat
e in
hig
h-ris
k ac
tiviti
es s
uch
as s
wim
min
g, h
orse
back
ridi
ng, c
anoe
ing
and/
or th
e ch
alle
nge
cour
se/c
limbi
ng w
all.
Alth
ough
car
e is
giv
en to
gre
atly
redu
ce th
e ris
k in
volv
ed th
roug
h sa
fety
pro
cedu
res,
edu
catio
n an
d eq
uipm
ent,
I und
erst
and
high
adv
entu
re p
rogr
ams
are
not w
ithou
t an
elem
ent o
f dan
ger.
I und
erst
and
the
risk
invo
lved
with
this
ty
pe o
f pro
gram
, and
I fe
el th
e be
nefit
s ou
twei
gh th
e po
tent
ial h
azar
ds o
f the
pro
gram
. My
child
has
per
mis
sion
to ta
ke p
art i
n an
d tra
vel t
o an
act
ivity
off
site
of c
amp
or b
etw
een
any
of th
e G
irl S
cout
s Lo
uisi
ana
Eas
t cam
ps a
s pa
rt of
the
plan
ned
activ
ities
fo
r my
child
’s c
amp
sess
ion.
__
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
__
Par
ent/G
uard
ian
Sig
natu
re
Dat
e EX
PEC
TED
CA
MPE
R B
EHA
VIO
R
Girl
s ar
e ex
pect
ed to
follo
w th
e G
irl S
cout
Pro
mis
e an
d La
w, l
iste
n an
d fo
llow
the
dire
ctio
ns o
f cou
nsel
ors,
use
the
budd
y sy
stem
, and
sta
y w
ithin
cam
p bo
unda
ries.
No
drug
s, a
lcoh
ol, p
ets,
or w
eapo
ns a
re p
erm
itted
on
cam
p pr
oper
ty. T
he c
amp
dire
ctor
rese
rves
the
right
to s
end
hom
e an
y ca
mpe
r who
neg
lect
s to
follo
w c
amp
rule
s, b
ecom
es a
dan
ger t
o he
rsel
f and
/or
othe
rs, o
r dam
ages
pro
perty
. No
refu
nd w
ill b
e gi
ven
if a
child
is s
ent h
ome
due
to m
isco
nduc
t. C
ELL
PHO
NE
AG
REE
MEN
T •
I und
erst
and
that
cel
l pho
nes
are
not a
ppro
pria
te a
t cam
p an
d I a
gree
to le
ave
my
cell
phon
e at
hom
e.
• I a
lso
unde
rsta
nd th
at if
I br
eak
this
rule
and
I am
foun
d w
ith a
cel
l pho
ne, t
he C
amp
Dire
ctor
will
hol
d ph
one
until
ch
ecko
ut.
• Th
e ca
mp
and
cam
p di
rect
or a
re n
ot re
spon
sibl
e fo
r los
t or d
amag
ed c
ell p
hone
s.
• I a
gree
to s
peak
to m
y un
it co
unse
lor i
n th
e ev
ent o
f an
emer
genc
y, h
omes
ickn
ess,
etc
. so
that
my
need
s ca
n be
ad
dres
sed.
__
____
____
____
____
____
____
____
____
____
____
____
____
____
_
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Par
ent/G
uard
ian
Sig
natu
re
D
ate
Cam
per S
igna
ture
D
ate
____
____
____
____
____
____
____
____
____
____
____
____
____
__
___
____
____
____
____
____
____
____
____
____
____
____
____
____
P
rint N
ame
of P
aren
t/Gua
rdia
n
Prin
t Nam
e of
Cam
per
EMER
GEN
CY
CO
NTA
CT
(if p
aren
t/gua
rdia
n ca
nnot
be
reac
hed)
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
___
____
____
____
____
____
____
____
____
____
_ N
ame
R
elat
ion
to C
ampe
r
(___
____
_)__
____
____
____
____
____
____
___
(___
____
_)__
____
____
____
____
____
____
___
(___
____
_)__
____
____
____
____
____
____
_ H
ome
W
ork
C
ell
RA
CIA
L B
AC
KG
RO
UN
D
q A
mer
ican
Indi
an, A
lask
an N
ativ
e q
Asi
an
q B
lack
, Afri
can
Am
eric
an
q H
awai
ian,
Pac
ific
Isla
nder
q
Whi
te q
Oth
er
ETH
NIC
BA
CK
GR
OU
ND
q
His
pani
c or
Lat
ina
q N
ot H
ispa
nic
or L
atin
a
q P
leas
e ch
eck
if yo
ur c
hild
nee
ds s
peci
al a
ssis
tanc
e, i.
e. d
ieta
ry, m
obili
ty, i
nter
pret
er, e
tc. W
e w
ill m
ake
ever
y ef
fort
to
acc
omm
odat
e al
l girl
s w
here
pos
sibl
e. P
leas
e ex
plai
n.
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
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MA
IL REG
ISTRA
TION
FOR
MS TO
: G
irl Scouts Louisiana East P
LEA
SE
PR
INT C
LEA
RLY
545 Colonial D
rive w
ww
.gsle.org Front &
Back Form
B
aton Rouge, LA
70806
OV
ER
à
Resident C
amp R
egistration Form
• Include $50 non-refundable deposit per session.
• M
ail to address listed above or fax with credit card inform
ation to (225) 927-8402. •
A separate registration form
and deposit is required for each camper.
• R
egistration form m
ust be filled out completely to be processed.
• O
ne camper and one session per form
.
CA
MPER
INFO
RM
ATIO
N
Cam
per’s Full Nam
e _____________________________________________________________________________________
Address ___________________________________________________ P
arish _____________________________________
City _____________________________________ S
tate_____ Zip____________ Age______ D
ate of Birth ________________
Registered G
irl Scout (check one)
q Y
es q
No G
rade entering in Fall _______ Troop # ________
______________________________ (______)__________________ (______)_________________ ________________________________ P
arent/Guardian
Day
Cell
Em
ail
______________________________ (______)__________________ (______)_________________ ________________________________ P
arent/Guardian
Day
Cell
Em
ail
This camper is in the custodial care of ______________________________________________________________________
BU
DD
Y INFO
RM
ATIO
N
Nam
e of girl(s) your camper w
ould like to have in the same cabin. C
ampers m
ust request each other and submit form
s by walk-in or by m
ail in the sam
e envelope. Placem
ent cannot be guaranteed.
Buddy N
ame(s) _________________________________________________________________________________
RESID
ENT C
AM
P PRO
GR
AM
/CO
DE
1st Choice _____________________________________________________________ _________________________________
Program
Nam
e
C
ode 2nd C
hoice ____________________________________________________________ _________________________________ P
rogram N
ame
Code
T-shirt size: q
YS
q Y
M q
YL q
AS
q A
M q
AL q
AX
L q A
XX
L C
amp Fee C
hecklist Am
ount
Session Fee
(Total balance is due 3 weeks prior to cam
p session.) $
*Mem
bership R
egistration Fee
IF NOT currently a registered G
irl Scout, please include $15 Girl Scout M
embership fee. Please register m
y cam
per as a Girl Scout for the 2015 m
embership year.
Parent/Guardian Signature ___________________________________________
$
SUB
-TOTA
L Total C
amp Fees
$
Deposit(s) D
ue w
ith this form
$50 non-‐refundable deposit *must be included w
ith this form.
Payable with Cash, Credit Card, Check or Santa’s certificate(s).
– $ 50.00*
You have the option to pay an additional am
ount towards your balance, please indicate it in the box to the right.
D
UE three w
eeks prior to your camper’s session. —
Total Balance D
ue $
Check m
ethod of payment:
q C
ash q M
astercard q V
isa q D
iscover q A
ME
X
q D
ebit q C
heck q M
oney Order
q S
anta’s Certificate(s) m
ust be enclosed with this form
. Am
t. $______
Credit C
ard Num
ber:
____________ – ____________ – ____________ – ____________
Expiration D
ate: ______________________
Print C
ardholder’s Nam
e X
______________________________________________________
Cardholder’s Signature
X ____________________________________________________
o
Check here if requesting C
amp Scholarship
Attach C
amp Scholarship application to this registration. (A
pplication are DU
E by March 15, 2015)
CHECK how
you want the
confirmation packet sent to you.
q Em
ail q Postm
aster
entering GRADES 6, 7, & 8
boots and bridles Love to ride? Don’t have much experience? Come to Marydale for a week of skill-building and trail riding. You will have a chance to improve your riding skills, and learn some new ones. When you aren’t horsin’ around, enjoy archery, swimming, and the challenge course. at CAMP MARYDALE, $325 DATE CODEMay 31-June 5 MDBB01June 21-26 MDBB02
star gazers Expect to “geek out” during this 11-day session! Stay up late and learn about astronomy, see the stars, tent camp under the night sky, play night time games, and take a dip in the pool after dark. During the day time, enjoy all that camp has to offer with canoes, archery, and more! at CAMP MARYDALE, $375DATE CODEJune 21-July 1 MDSG0
girl scout survivors During this 11-day session, you will have the opportunity to explore all that Girl Scout camps have to offer while learning key survival skills! Learn how to build a shelter and how to start a fire with no matches. Go horseback riding at Camp Marydale and challenge yourself on the high ropes and rock climbingcourseatCampWhisperingPines.Takeakayaktripdownthe Tangipahoa River and camp-out at the end of the trip! In your spare time, take a trip down the lake slide, a dip in the pool, and make some pretty awesome arts & crafts. Be prepared to cook over a fire and tent camp several times during your adventure! **This session includes travel between camps.** at CAMP MARYDALE/WHISPERING PINES, $375 DATE CODEJune 21-July 1 MDGSS1
saddle up Are you a seasoned rider? Want to take your knowledge to the next level? This advanced session is for you! Spend your time learning about equine first aid, nutrition, and different riding disciplines. When you aren’t learning, you’ll be practicing your trail riding skills! at CAMP MARYDALE, $325DATE CODEJuly 12-17 MDSU01
11
girls AGES 11 through 13
spur in training Ready to be a Wrangler, but just not old enough? Try out the Spur in Training program, designed especially for those girls who are eager totraintobecomea“Spur”inMarydale’sWrangler/SpurProgram.You will spend the week learning the ropes by assisting the Wranglers and riding staff at the barn, caring for the horses and, in your spare time, riding! **The focus of this program is not riding—it is learning leadership skills for the Wrangler/Spur Program.** at CAMP MARYDALE, $175DATE CODEJune 7-12 MDSIT1June 14-19 MDSIT2July 12-17 MDSIT3
entering GRADES 6 through 10
thrill seekers Areyouathrillseeker?JoinusatCampWhisperingPinesandspend the week going through challenges. Learn the ins and outs of the High Ropes Course–practice rescue techniques and knots used on the course. You will learn new boating techniques and even take a short trip on the lake. So, practice your packing skills–becauseyou’llbeeatinginyourboat!Practicepitchingatent and listening to the night life, because you’ll be doing just that all week! at CAMP WHISPERING PINES, $300DATE CODEJune 7-12 WPTS01June 21-26 WPTS02
entering GRADES 7 through 10
night riders Are you an intermediate to advanced rider looking to have a little fun on horseback? In this session, you will have a chance to ride at night (in a lit arena) while you work on your horsemanship skills, play rodeo games, and even take a trail ride at dusk. You will participate in an overnight trail ride where you’ll ride your horse to your camping site, pitch a tent, and listen to the many sounds of the night. at CAMP MARYDALE, $300DATE CODEJuly 5-10 MDNR04
12
entering GRADES 7 through 12
all aboard CampWhisperingPinesisyourdestinationforaquaticthrills.Thiswatersession is filled to the gills with kayaking and canoeing on the lake, tubing down the Tangipahoa River, swimming in the pool and lake, going down the Timber Lake Slide, and camping in tents on the barge. There will be a lot more to explore around camp, too. at CAMP WHISPERING PINES, $300DATE CODEJuly 5-10 WPAA01
entering GRADES 8 through 12
trail blazers Four-day horse campout – Advance SkillsSaddle up Cowgirls! Trail Blazers is the perfect short session for those girls who LOVE to trail ride! As a special treat for this outfit, Trail Blazers will take their gear out for a sleepover trail ride, cook over a fire, and develop outdoor living, horsemanship, and horseback riding skills. This session is short, so campers MUST be intermediate to advanced riders to participate in all portions of Trail Blazers. at CAMP MARYDALE, $225DATE CODEJune 28-July 1 MDTB01
entering GRADES 9 through 12
wrangler in training I Discover your leadership and horsemanship potential. Explore the basics of assisting the riding program at Marydale. You will spend one week learning the ropes of being a Wrangler by assisting the Riding Staff at the barn, caring for the horses and, in your spare time, riding! **The focus of this program is not riding–it is learning leadership skills for the Wrangler Program.** at CAMP MARYDALE, $150DATE CODEMay 31-June 5 MDWIT1
13
entering GRADES 9 through 12
wrangler in training II Once you have completed Wrangler in Training I, you are eligible for Wrangler in Training II. Come spend your time at camp teaching younger girls how to care for and ride horses. Share your love of horses with other girls to foster their own special connection with the herd. **The focus of this program is not riding—it is learning leadership skills for the Wrangler Program.** at CAMP MARYDALE, $275DATE CODEJune 7-19 (2 weeks) MDWIT2
barn aide Are you looking for a special way to spend your summer and have already completed WITs I & II? Spend several weeks at the Camp Marydale barn sprucing up the teaching methods you already know, establishing your leadership and decision making skills, and leading trail rides. Send your application to Angela Arneal at [email protected] for consideration of the Barn Aide position. *The focus of this
program is not riding. Campers go home each weekend.* at CAMP MARYDALE , $100 (**EXCEPT MDBA05, $75)DATE CODEMay 31-June 5 MDBA01June 7-12 MDBA02June 14-19 MDBA03June 21-26 MDBA04June 28-July 1** MDBA05July 5-10 MDBA06July 12-17 MDBA07
entering GRADES 10 through 12
counselor in training I Have you always dreamed of being a summer camp staff member? Welcome to the first step… the CIT program! This session gives girls a chance to start developing skills as future camp counselors. Learn counseling and leadership skills, behavior management techniques, role play situations, and new songs. You will learn to help with camp activities, work with younger campers, and of course, have fun!
at CAMP WHISPERING PINES, $125DATE CODEJune 7-12 WPCIT1
at CAMP MARYDALE, $125DATE CODEJune 21-26 MDCIT1
14
entering GRADES 10 through 12
counselor in training II If you have already completed Counselor in Training I, you will learn to work with staff and campers of all backgrounds and ages, hone your skills as a facilitator at program areas, and get certified in First Aid andCPR.Attheendofyourtraining,youwillbeplacedwithaunitasajuniorstaffmembertoputallyour training and knowledge in practice. CITs go home on the weekend.
at CAMP WHISPERING PINES, $125DATE CODEJune 21-26 (1 week) WPCIT2at CAMP MARYDALE, $225 DATE CODEJuly 5-17 (2 weeks) MDCIT2
program aide After you have completed CIT I & CIT II, consider applying for theProgramAideposition.ProgramAideswillhelpfacilitateprogram areas such as arts & crafts, swimming, canoeing, and challenge course. You might also help out in the units, the office, orthedininghallaswell.ProgramAidesmustbeavailableforapre-camp training. Turn in your application to Angela Arneal at [email protected]. at CAMP MARYDALE , $100 (**EXCEPT MDPA05, $75)DATE CODEMay 31-June 5 MDPA01June 7-12 MDPA02June 14-19 MDPA03June 21-26 MDPA04June 28-July 1, 2015** MDPA05July 5-10, 2015 MDPA06July 12-17, 2015 MDPA07
program aide AfteryouhavecompletedCITI&CITII,considerapplyingfortheProgramAideposition.ProgramAides will help facilitate program areas such as arts & crafts, swimming, canoeing, and challenge course.Youmightalsohelpoutintheunits,theoffice,orthedininghallaswell.ProgramAidesmustbe available for a pre-camp training. Turn in your application to Angela Arneal at [email protected]. at CAMP WHISPERING PINES , $100 (**EXCEPT WPPA03, $75)DATE CODEJune 7-12 WPPA01June 21-26 WPPA02June 28-July 1** WPPA03July 5-10 WPPA04
15
Resident Camp Registration Information
placement begins February 2! Mail in your registration to Girl Scouts Louisiana East, 545 Colonial Drive, Baton Rouge, LA 70806.
Non-Refundable Registration Deposit: $50 In anticipation of a camper’s attendance, various expenses are incurred on her behalf, such as supplies, equipment, registration and camp staffing costs. Accordingly, there is a non-refundable $50 deposit for each session requested due with the registration form. Forms received without the deposit(s) will be returned. Cash, credit card, check, or money order are accepted for deposit payment. As the registration process continues, this deposit is applied to the session fees. However, if the participant cancels a session, the deposit is retained. If the council must cancel a session, the deposit will bereturned.Pleasenotethatthedepositisnottransferabletoanother camper. Cookie Dough is not accepted as payment for the deposit (but is acceptable for the remainder of camp fees). ** Make your doctor’s appointment today for your physical examination. Don’t forget to bring the enclosed Girl Health Examination Record.
BALANCE DUEThe balance of the camp fee must be received at either council office three weeks prior to session. NO FEES WILL BE ACCEPTED AT CAMP.
REFUNDSPartialrefunds(lessnon-refundabledeposit)maybegiven in some instances and are considered on a case by case basis. Written requests for a refund must be received by the council at least three weeks prior to the opening day of the session. A partial refund (less non-refundable deposit) may be secured if the council receives a written certificate from a licensed M.D. stating she is unable to attend her camp session or if there is a family emergency.
No refund will be given if a camper is sent home due to unacceptable behavior or homesickness. Full refunds will only be issued for sessions canceled by the council.
CAMP SCHOLARSHIP Financial assistance is available for one camp session to those demonstrating financial need and will be a percentage of the session fee. Confidential camp scholarship request applications are due by March 15, 2015. After this date funds may be limited, but applications will be accepted for review. If you wish to request financial assistance, please complete the form and attach it to your daughter’s registration form. Deposits are still required with a completed financial assistance form. Return the confidential application with your daughter’s camp registration form. Only girls registered with the Girl Scouts Louisiana East council are eligible for financial assistance.
GIRL SCOUT COOKIE DOUGHGirls who earn Cookie Dough or Nutte Bucks may use it toward the balance of the camp fees. Pleasenoteontheregistrationform if you have not received your certificate but are eligible. Cookie Dough cannot be used as a deposit.
MULTIPLE SESSION DISCOUNTGirl Scouts who attend more than one session will receive a $25 discount applied to each additional camp session.
CONFIRMATIONSAfter registration forms and deposits have been received and processed, confirmation packets will be sent via email or mail indicating placement in camp session(s), balance due, and detailed information on what to pack, trading post, etc. It will take some time to process registrations. If you are curious about the status of your confirmation packet, please call no earlier than May 1, 2015.
16
MAIL REGISTRATION FORMS TO: Girl Scouts Louisiana East PLEASE PRINT CLEARLY 841 S. Clearview Pkwy. www.gsle.org New Orleans, LA 70121
GSLE 11/14
Girl Scout Camp Scholarship Request Any active registered Girl Scout in Girl Scouts Louisiana East may apply for a camp scholarship to attend one camp session.
Complete the camp registration form and camp scholarship request and send both to the Girl Scout Office by March 15 to be eligible for first round of allocations. After this date, funds may be limited. TO BE COMPLETED BY PARENT OR GUARDIAN: _______________________________________________ ___________________________________________________ Camper’s Name Parent/Guardian _______________________________________________ _________________________________ _______________ Address City, State Zip
(______)___________________ (______)__________________ (______)__________________ ________ Home Work Cell Grade in Fall
Is she a: q Registered Girl Scout: Troop # _______________ Service Unit # _____________ q Individual Member
Program Age Level in Fall: q DA/BR q JR q CAD q SR/AMB
No. of Years as a Girl Scout ____ Did she participate in the most recent Girl Scout Fall Product and Cookie Sales? q Yes q No
How often does she participate in Girl Scout activities, meetings, etc.? ______________________________________________ ________________________________________ (______)__________________ (______)_______________ Leader’s Name Home Work / Cell
Family Income: q Under $15,000 q $15,000 - $25,000 q $25,000 - $35,000
q $35,000 - $45,000 q $45,000 - $55,0000 q OVER $65,000
Number of people supported by this income ____________ Number of dependent children living at home ______________
List any unusual or extraordinary family expenses or circumstances (Attach a letter if necessary!) ___________________
______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ___________________________________________________________________________ ______________________ Program your camper would like to attend Dates Amount of Fee $ ____________________________________ Amount you can pay $ ____________________________________
Has she received financial assistance from the Girl Scouts before? q No q Yes —When, amount received and for what
purpose? ______________________________________________________________________________________________
Signature _____________________________________________________________ Date ___________________________
q Parent/Guardian q Troop Leader q Other
Although not required, partial or full reimbursement (when and if possible) of any funds granted is appreciated and accepted at any time. This enables your council to continue to provide assistance for girls and adults when the need arises.
OFFICE USE ONLY: Amount Granted: $____________ Total Due from applicant $_____________ Appv’d by__________ Date_________ Program Cost: $____________ ________________________% authorized
Receipted by ______________ No. ______________ date ______________ DATA ENTRY: by __________ date __________
545 Colonial Drive Baton Rouge, LA 70806
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