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The Girl Scout

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A P A R T O F T H E G S S J C T R A V E L T O O L K I T

. The Girl Scout Appendix

Table of Contents

Online Resources ...........................................................................................................03

World Association of Girl Guides & Girl Scouts ...................................................05

Safety Checklist for Travel Readiness .....................................................................07

Safety Tips for Girls Traveling Alone ........................................................................09

Travel Procedure for Visiting the Juliette Gordon Low .....................................09 Girl Scout National Center Money Makes You Go Round the World .................................................................10

Individual Worksheet ....................................................................................................11

Crunch the Numbers Chart ........................................................................................12

Daily Travel Itinerary ......................................................................................................13

Forms .....................................................................................................................14

A“Is She Ready?” Travel Progression Chart .....................................................14 Short Troop/Group Trip Form (F-413) ...............................................................21 Extended Troop/Group Trips – Notification of Intent to Plan (F-453) ...22 Extended Troop/Group Trips – Initial Plan (O-883) .....................................24 Extended Troop/Group Trips – Application for Approval (O-884) .........26 Signed Parent/Guardian Permission Slip (F-204) .........................................28 Girl Health Form (F-185) .........................................................................................29 Adult Health Examination Form (O-905) .........................................................31 Power of Attorney for Girl Travel (F-318) ..........................................................32 Power of Attorney for Adult Travel (O-906) ....................................................33 Girl Behavior Agreement (O-903) ......................................................................34 Adult Behavior Agreement (O-904) ..................................................................35 Extended Troop/Group Trips – Evaluation (O-927) .....................................36 Girl Application for Trip – Template ...................................................................38 Girl Interview for Trip – Template ........................................................................43 Adult Travel Application for Trip – Template ..................................................48 Adult Interview for Trip – Template ....................................................................49 Volunteer Agreement for Trip Advisor ...............................................................51 Girl Outcome Evaluation Form for Girl Scout Travel ....................................52 Volunteer Trip Evaluation .......................................................................................55

Girl Outcome Evaluation Form for Girl Scout Travel .................................... Volunteer Trip Evaluation .......................................................................................


Air Travel • Transportation Security Administration

www.tsa.gov/travelers

Communication • Country and city dialing codes:

www.business.att.com/bt/dial_guide.jsp • Phone card tips:

www.ekit.com/ekit/about/phonecardfeatures

Consulates and Embassies • Embassies and consulates worldwide:

www.usembassy.gov/ • U.S. State Department: www.state.gov/

Culture • The CIA’s World Factbook, with detailed information on

every country: https://www.cia.gov/library/publications/the-world-factbook/index.html

• Culture Grams—concise, up-to-date reports on more than 200 countries: www.culturegrams.com/

• Culture Matters, developed by the Peace Corps, helps visitors interact respectfully in other cultures: www.peacecorp.gov/wws/educators/enrichment/culturematters/index.html

• “Culture Shock”—tips for easing cultural adjustment: http://www.cie.uci.edu/prepare/shock.shtml

• What’s Up With Culture prepares students for cultural immersion: www.pacific.edu/sis/culture/

Health • Travelers’ health, Centers for Disease Control and

Prevention: http://wwwn.cdc.gov/travel/• The Travel Clinic offers information on travel-related

health matters: www.drwisetravel.com/index.html• IAMAT’s advice on health risks, required immunizations,

and medical care abroad: www.iamat.org

Insurance • Mutual of Omaha’s Girl Scout insurance:

www.mutualofomaha.com/girl_scouts_of_the_usa

Money• Currency converter: www.xe.com/ucc/ • Mastercard ATMs overseas:

www.mastercard.com/cardholderservices/atm/ • Visa ATMs abroad:

visa.via.infonow.net/locator/global Passport/Visas• Passport-issuing offices:

www.travel.state.gov/passport/• “Where to Write for Vital Records” tackles birth

certificate application: www.cdc.gov/nchs/howto/w2w/w2welcom.htm

• Country-specific entry regulations: http://travel.state.gov/travel/

Planning• Abroad View’s travel basics:

www.abroadview.org/going/travel/index.htm• University of Michigan’s travel abroad resource:

www.internationalcenter.umich.edu/swt/travel/

People with Disabilities • “Disability travel and recreation resources”:

www.makoa.org/travel.htm• Mobility International USA offers opportunities for

international exchange and useful travel information: www.miusa.org

Safety and Emergency Preparedness • Safety Abroad First’s “Top Ten Ways to Not

Become a Victim of Crime Around the World”: www.globaled.us/safeti/toptennotvic.html

• U.S. State Department’s emergency assistance: http://travel.state.gov/travel/tips/emergencies/emergencies_1212.html

• Sara’s Wish Foundation provides helpful safety tips for traveling abroad: www.saraswish.org/travel_safety_guidelines.htm

Travel Guides and Resources• U.S. Department of State offers information on

traveling abroad: http://travel.state.gov/ • Tourism Offices Worldwide Directory:

www.towd.com/

Online Resources

Continued...


• Let’s Go offers popular student guidebooks:

www.letsgo.com/ • Lonely Planet’s guidebooks for budget travelers:

www.lonelyplanet.com/destinations/ • Rough Guides publishes guidebooks for budget

travelers: www.roughguides.com/ • Moon handbooks provide in-depth cultural and

practical information: www.moon.com/ • Footprint offers comprehensive travel guides:

www.footprintbooks.com/

Travel Providers • STA Travel is a student travel agency offering discounted

air and rail fares, as well as the International Student Identity Card (ISIC): www.statravel.com/

• Hostelling International offers customized Girl Scout adventures and global education programs: www.hiusa.org/programs/girls-scouts.shtml

• EF Tours offers Girl Scout troops and groups customized educational tours to the WAGGGS world centers and more than 50 countries around the world: www.eftours.com

• Global Explorer’s trips focus on science, culture, leadership, and service to help girls understand that they are part of a much larger, interconnected world, and that their actions have an impact on that world: www.globalexplorers.org

Your Next Adventure Abroad• Rotary International provides scholarships abroad: www.

rotary.org/programs/index.html• Council for International Education Exchange offers study

and work abroad programs: www.ciee.org/• AFS-USA summer and year-long exchange opportunities:

www.usa.afs.org/usa_en/home • Youth for Understanding summer, semester, and year-

long exchange opportunities: www.yfu.org/• Study abroad programs: www.studyabroad.com/ • Opportunities for volunteering abroad:

www.volunteerabroad.com/

Online Resources (continued)


Worldwide MovementThe World Association of Girl Guides and Girl Scouts (WAGGGS) is comprised of 145 member organizations which promote mutual understanding and cross-cultural opportunities for girls around the world. Girl Scouts of the USA is one of the 145 Member Organizations. The goal of WAGGGS is to enable girls and young women to develop their full-est potential as responsible citizens of the world.

World Centers The four world centers, Our Cabaña in Cuernavaca, Mexico; Our Chalet in Adelboden, Switzerland; Pax Lodge in London, England; and Sangam in Pune, India, are owned and operated by the World Association of Girl Guides and Girl Scouts (WAGGGS). Staffed by volunteers and paid international staff, the centers offer Girl Guides and Girl Scouts a comfortable, inexpensive, and safe place for short stays or long-term accommodations, seminars, trainings, and international events. Members of Girls Scouts of the USA and their families are encouraged to visit the centers, meet girls from other countries, and build lasting friendships.

Our Cabaña (www.ourcabana.org/), located 47 miles from Mexico City, is a beautiful retreat located in historic Cu-ernavaca. Our Cabaña is the largest of the four world centers, can accommodate up to 90 guests, and offers five-, eight-, and nine-night sessions throughout the year to girl and adult members of WAGGGS and GSUSA, including Girl Friendship sessions and Adult Adventure programs.

Our Chalet (www.ourchalet.ch/) was the first world center built by WAGGGS. Located in the picturesque Swiss Alps, Girl Scouts, Girl Guides and their families can explore the network of trails and footpaths that lead to snow-capped peaks, crystal-clear waters, alpine forests, and wild flower meadows. Our Chalet offers a wide array of programs from high-adventure activities such as skiing or hiking to leadership seminars.

Pax Lodge (paxlodge.wagggsworld.org), located in Hampstead Village, 20 minutes by subway from the center of London, is an ideal base for exploring the city’s rich history, tradition, and culture. This world center offers a vibrant selection of cultural programs for youth and adults as well as leadership seminars and day activities.

Sangam (www.sangamworldcentre.org), situated along the banks of the Mula River in Pune, India, is a few hours from Mumbai (Bombay). Sangam, which means “coming together” in Sanskrit, brings Girl Guides and Girl Scouts together from around the globe. Events, scheduled from June to March, emphasize cultural sharing, common Girl Guiding/Girl Scouting links, and the rich cultural heritage of India.

DressGirl Guides and Girl Scouts are expected to wear their official Girl Scout uniforms or camp uniforms when visiting the world centers. Continued...

World Association of Girl Guides and Girl Scouts (WAGGGS)


AtmosphereThe informal atmosphere of the world centers encourages interaction among visitors who are expected to contribute to the daily operation of the facility. As space in these facilities is limited, visitors are asked to bring only essential items.

GiftsContact the center before your visit to find out what is needed to maintain operations, or contact the World Foundation (www.worldfoundationgggs.org/), a private nonprofit that supports the world centers.

VisitsContact the world centers directly to inquire about accommodations, programs, and events.Our Cabaña: www.ourcabana.org/Our Chalet: www.ourchalet.ch/Pax Lodge: paxlodge.wagggsworld.orgSangam: www.sangamworldcentre.org

VolunteeringThe world centers offer volunteer opportunities for Girl Scout members 18 years old and above. www.girlscouts.org/who_we_are/global/wagggs/world_centers_volunteers

The World Association of Girl Guides and Girl Scouts (WAGGGS) is comprised of 145 member organizations which promote mutual understanding and cross-cultural opportunities for girls around the world. Girl Scouts of the USA is one of the 145 Member Organizations.

World Association of Girl Guides and Girl Scouts (WAGGGS) (continued)


Here is a checklist of general indicators for leaders and girls to look for to determine group readiness for a trip. Group consultants and others who review the travel plans should also find the checklist useful. Program services personnel can use the checklist as they approve travel plans, evaluate trips, and make trip recommendations.The following statements show travel readiness:

1. The trip upholds Girl Scout policies and standards.• The trip meets all appropriate safety guidelines provided by your council and Volunteer Essentials.

2. There is communication with the council.• All appropriate permissions have been obtained from the council.• Adult volunteers and girls know and follow council policies on camps and overnight trips,

including procedures for handling emergencies.• Council staff are informed of any changes in plans.

3. There is sound planning.• The trip has a clear purpose, formulated and understood by the girls and adults.• The trip is part of ongoing group activities, with all participants included in the planning steps.• Girls work successfully in groups and accept the responsibilities involved in the trip.• The proper number of adult chaperones who accept the responsibilities of the trip have been recruited.• Girls and their parents or guardians support the project wholeheartedly; parents or guardians understand

all plans and have confidence in the leadership.• Girls and adults together make realistic, detailed plans well in advance.• Plans consider the special abilities and the religious and ethnic diversity of the participants and of those

they will interact with during the trip.• Girls and adults learn in advance as much as possible about what they will be seeing and doing.• The group seeks council guidance and approval on the best means of transportation for the trip.

4. Travel arrangements are made in advance.• Time is provided for eating, sleeping, rest and relaxation, recreation, and personal needs.• Mileage to be covered each day is reasonable for the terrain expected.• Plans consider both drivers and passengers.• Reservations for overnight accommodations are confirmed in writing, and all stopping places are planned in

advance. Sufficient space is reserved so that each girl has her own bed. If girls will be sharing beds, this should be clearly conveyed to the parent/guardians in the permission slip. Under no circumstances will a girl share a bed with an adult.

• The entire itinerary is known to girls, adults, parents, the council, and the back-home emergency contact.

5. Business and money matters are worked out.• Girls and adults create a detailed, realistic budget, remembering to include such items as transportation,

food, tips, insurance, recreation, admission fees, taxes, and emergency funds.• Money-earning projects are carried out with the permission of the council and in accordance with Girl Scout

policies and Program Standards.• Personal and group expenses are defined. The amount of personal money needed and how those funds

should be handled are determined in advance.• Group travel funds are kept in a bank account before the trip and carried securely during the trip.

Continued...

Safety Checklist for Travel Readiness


• One person is responsible for group funds and will keep a daily account of expenditures. However, all funds should not be held by just one person at any time during the trip.• Decisions are made in advance about how to pay bills that occur before the trip, en route, and afterward.

6. Members take responsibility for personal conduct and equipment.• Girls and adults know what clothing and equipment to take and how to use and pack the equipment.• When the group travels in uniform, all travelers have a Girl Scout uniform. Girls and adults are expected to be

in official uniform to represent Girl Scouts of the USA and respect the traditions of the Girl Guide and Girl Scout movements when traveling internationally to events and opportunities at world centers and other Girl Guide/Girl Scout international activities.• Girls understand their responsibilities as travelers. Everyone is briefed on appropriate conduct and safety

precautions in public places, restrooms, escalators, and elevators, as well as on building stairs and selected forms of transportation.• Groups staying in hotels are prepared to take special precautions to protect their own safety and know what

to do in case of fire.• Special equipment required, such as tents, bicycles, canoes, etc., is checked and ready well before the

departure date.• Individual limits on luggage and equipment are set and adhered to. Each person is able to carry her own

individually identified belongings except when a special consideration, such as a disability, warrants alternative plans. All valuables are left at home.

7. Everyone knows and observes good health and safety practices.• Volunteer Essentials is used when preparing for any trip. Girls and adults also consult council resources.• Required health examinations and immunizations are completed. Health records, medical waivers, necessary

medications, eyeglass and contact lens prescriptions, and/or extra eyeglasses are taken along.• Everyone is physically and mentally able to take the trip. Reasonable accommodations are made for

girls who have disabilities.• For trips of a day or more, at least one currently certified first-aider is present. The council office is contacted

to determine the level of first-aid training needed.• Provisions are made for first aid.• For trips of three nights or more, insurance coverage is obtained for the entire trip through the council under

one of the optional accident or accident and sickness plans available. For international trips, request information from your council about the comprehensive foreign travel insurance and travel assistance program provided by Mutual of Omaha. • Arrangements have been made for an adult contact back home for routine reporting as well as for emergencies.• Written itineraries, including telephone numbers and addresses, are prepared for girls, their families, the council

office, and the back-home contact. On overseas trips, the written itineraries include U.S. embassy and consulate locations.• Everyone understands procedures for handling accidents, illnesses, and emergencies.• Trip leaders for specialized trips, such as canoeing or backpacking, have taken water safety and leadership

training for the activity and are familiar with the Girl Scout Program Standards and activity checkpoints set forth by your council.• Necessary insurance forms are carried, along with all important papers.

Safety Checklist for Travel Readiness (continued)


If a Girl Scout Cadette, Senior, or Ambassador will be traveling alone during any part of a trip, use the opportunity to help her feel comfortable with and capable of being on her own. Always talk first with her parents to assess her maturity and ability to handle herself, and have them complete an emergency form. If she is flying, also discuss the possibility of booking a nonstop flight to make her trip that much less stressful, and ask parents to contact the airline, which will make special arrangements for any unaccompanied minor. With the girl herself, develop a trip plan, discuss hotel security and safety, and talk about avoiding excess communication with strangers, not wearing a nametag, and avoiding exposing money or other items (such as smartphones, iPads, and iPods) that are attractive to pickpockets.

Tips for Girls Traveling Alone

The Juliette Gordon Low Girl Scout National Center provides year-round educational opportunities for Girl Scout Juniors, Cadettes, and Seniors and Ambassadors in Savannah, GA. Reservations and council approval are required for visiting the Birthplace. Most programs are booked a minimum of one year in advance. Families and individuals do not need a reservation for a tour. For information about specific programs and days and hours of operation, or to request a copy of Birthplace Bound, a booklet summarizing educational programs, schedules, and fees as well as lodging, camping, restaurants, and sightseeing opportunities, contact the center by calling 912-233-4501, faxing 912-233-4659, or writing the Juliette Low Center at 10 East Oglethorpe Ave. Savannah, Georgia 31401.

Visit the website: http://www.juliettegordonlowbirthplace.org/

Travel Procedures for Visiting the Juliette Gordon Low Girl Scout National Center

HI hostels are more than an affordable source of accommodation. Hostelling International USA offers programs, discounts, learning experiences, and the opportunity to share your travel experiences. Their mission has always been “To help all, especially the young, gain a greater understanding of the world and its people through hostelling.”

Program and Learning Opportunities• Volunteer opportunities• Service projects or collaborations with other groups and non profits• Walking tours• Girl Scout patches and programming specifically prepared for Girl Scouts• Cultural kitchens• Campfires• Troop Planning 101 Workshops are offered to Juniors - Ambassadors in the fall and spring

Available upon request, HI offer a series of travel presentations:• World Travel 101 Nuts and Bolts and World Travel 101 Intercultural Educations• Women Traveling Solo• Discover the World Patch Program – Girl Scouts• For more information, go to www.hihostels.com and find out what programs your local HI office offers.

Hostelling International


ExPENSES COST fOR GROuP COST fOR YOu

Passport $________ $________Airfare $________ $________Lodging $________ $________Food $________ $________Event Fees $________ $________Souvenirs, gifts $________ $________Local transportation $________ $________Miscellaneous $________ $________Emergency money $________ $________Admission fees (museums, theater, etc.) $________ $________Total $________ $________

Money Makes YOu go ‘Round the World


ExPENSES COST fOR YOu NOTES

Passport $________

Airfare $________

Lodging $________

Food $________

Event Fees $________

Souvenirs, gifts $________

Local Transportation $________

Miscellaneous $________

Emergency money $________

Admission fees (museums, theater, etc.) $________

Total $________

Individual Worksheet


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Crunch the Numbers Chart


DATE

Time

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Time

Schedule

Schedule

Schedule

Notes

Notes

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8:00

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9:00

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2:00

3:00

4:00

5:00

daily Travel Itinerary

GSSJC F-453 Rev. 7/11

NOTIFICATION OF INTENT TO PLAN

Extended Troop/Group Trips Girl Scouts of San Jacinto Council

5 plus nights away from Council / or Troop/Group # Jr Cad Sr Ambany trip over state lines Service Unit Trip DestinationDUE 12-24 MONTHS PRIOR TO TRIP Trip Dates (if international trip, 2 years recommended)

E-Mail to the Extended Troop/Group Trip Coordinator at [email protected] OR mail to Extended Troop/Group Trip Coordinator, Girl Scouts of San Jacinto Council, 3110 Southwest Freeway, Houston, TX 77098. An approval will be sent via e-mail to the leader for troop/group records.

Trip Leader’s Name

Cell Phone Home Phone Office Phone

Address Street City Zip Code

Email Address

How long have you been a Girl Scout Volunteer? Of this troop/group

Number of girls in troop/group

Number at each age, at trip time: 9 10 11 12 13 14 15 16 17 18____

Number of adults going Women Men

Purpose of trip (i.e. Celebration, Education, Career Exploration):

What kind of trips has this troop/group taken? (indicate length and type) Asterisk any of these trips that you

attended as an adult chaperone

How many other trips are planned (but not yet taken) before this one? Describe

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GSSJC O-883 Revised 7/11

2. Secondary Girl Scout Insurance is required. Contact the Administrative Assistant to the Chief Financial Officer for more information at 713-292-0320. 3. Consider Girl/Adult Behavior Agreements for all travelers. See examples in forms GSSJC O-903 for girls and GSSJC O-904 for adults.

Estimated Income Information (Out-of-Pocket Expenses): Amount from girls: girls at $ per girl Total $ Amount from adults: adults at $ per adult Total $

Amount from troop/group funds: (List money raising plans, cookie bonus, etc., with amount expected from each. All money-raising projects must have prior approval of the Service Unit Manager or the Membership Department, depending on the type.) 1. Amount $ 2. Amount $ 3. Amount $

Estimated Expense Information (List below or attach your own budget records):

Transportation: (Give method of travel and show how cost is figured.)

Total $

Overnight Housing: (Give types of facilities and show how cost is figured.)

Total $

Food: (Show how cost is figured.)

Total $

Activities (Museum tickets, Grand Canyon tour, LEGO Land, et al): (Show how cost is figured.)

Total $

Insurance: Total $ Emergency Fund: Total $

Other: (Show how cost is figured for incidental expenses)

Total $

Grand Total $

*Reminder: The Application for Approval (GSSJC O-884) is due 2-4 months prior to trip.

For Office Use Only: Comments:

Approved By (Signature): Date:

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INITIAL PLAN


5 plus nights away from Council / or Troop/Group # Jr Cad Sr Amb any trip over state lines Trip Destination Trip Dates DUE AT LEAST 8-16 MONTHS Date Notification of Intent to Plan Approved PRIOR TO TRIP Notable Changes (if any) Include (16 months recommended for international trips)


Trip Leader’s Name:

Cell Phone Home Phone Office Phone

E-Mail Address:

Number of girls in the troop/group: Number of girls going on the trip:

Number at each age, at trip time: 9 10 11 12 13 14 15 16 17 18

Number of adults going: Women Men

Describe how girls are preparing themselves for this trip:

If all girls in the troop/group are not planning to go, describe how other troop/group program and trip planning are being handled (i.e. How are the other girls still involved?):

Is each member of your troop/group qualified for the activities on your proposed itinerary and/or have the proper certifications (swim cards, etc.)? ____Yes ____No

Read Safety-Activity Checkpoints and the GSSJC Resource Guide for participant and supervisor requirements and certifications, if necessary.

SEND COPIES OF CURRENT CERTIFICATIONS WITH THIS FORM. This includes copies of the adult First Aider/CPR / EMT / RN / Physician and other certifications as necessary. Enroll in appropriate classes if not currently qualified and send in copies of certifications when available.

Reminders:1. Permission Slip (F-204 for girls, F-22 for adults), Health Form (F-185 for girls, O-905 for adults) and Medical records are required for each traveler, and a Power of Attorney is strongly suggested (GSSJC F-318 for girls; GSSJC O-906 for adults).

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2. Secondary Girl Scout Insurance is required. Contact the Administrative Assistant to the Chief Financial Officer for more information at 713-292-0320. 3. Consider Girl/Adult Behavior Agreements for all travelers. See examples in forms GSSJC O-903 for girls and GSSJC O-904 for adults.

Estimated Income Information (Out-of-Pocket Expenses): Amount from girls: girls at $ per girl Total $ Amount from adults: adults at $ per adult Total $

Amount from troop/group funds: (List money raising plans, cookie bonus, etc., with amount expected from each. All money-raising projects must have prior approval of the Service Unit Manager or the Membership Department, depending on the type.) 1. Amount $ 2. Amount $ 3. Amount $

Estimated Expense Information (List below or attach your own budget records):

Transportation: (Give method of travel and show how cost is figured.)

Total $

Overnight Housing: (Give types of facilities and show how cost is figured.)

Total $

Food: (Show how cost is figured.)

Total $

Activities (Museum tickets, Grand Canyon tour, LEGO Land, et al): (Show how cost is figured.)

Total $

Insurance: Total $ Emergency Fund: Total $

Other: (Show how cost is figured for incidental expenses)

Total $

Grand Total $

*Reminder: The Application for Approval (GSSJC O-884) is due 2-4 months prior to trip.



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APPLICATION FOR APPROVAL


5 plus nights away from Council / or Troop/Group # Jr Cad Sr Amb any trip over state lines Trip Destination Trip Dates DUE AT LEAST 3 MONTHS Date Initial Plan Approved PRIOR TO TRIP Notable Changes (if any) Include


Trip Leader’s Name: E-Mail Address: Street Address: City: Zip Code: Number of girls in the troop/group: Number of girls going on the trip: Number at each age, at trip time: 9 10 11 12 13 14 15 16 17 18___ Number of adults going: Women Men

Names of Adults Address (w/zip code) Travel Experience / Volunteer Position

Name of current First Aider, EMT, RN, or Physician going on trip: Date First Aid certification expires: Emergency contact person at home: Name Phone

Describe your emergency contact plan to notify families at home, if necessary:

How have you informed the parents on the details of the trip?

What is your security plan to keep the group safe while traveling?

What do the girls still need to do before they are well prepared to take full advantage of the trip opportunities and take responsibility for their personal conduct (i.e. certifications, planning, forms)?

How will this be done (i.e. email, meeting, etc.)

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Give date you plan to collect: 1. Medical / Health Form 2. Power of Attorney Form 3. Passport (if necessary)

Final Budget Information (or attach your own budget records)

Expenses Income Transportation Individual Fees Lodging Troop Funds Food Other Sources: Activities Insurance Emergency Fund Other TOTAL TOTAL

Suggested spending money per girl: Amount of money in the bank now:

* Short-term activity insurance must be purchased for trips lasting more than two nights. Contact Adriene Crosby, Administrative Assistant to the Chief Financial Officer, for details if you haven’t done so already. She can be reached at 713-292-0320, [email protected].

THIS APPLICATION IS NOT COMPLETE WITHOUT THE FOLLOWING TWO ITEMS:

1. A roster with all travelers’ names, complete mailing addresses, parents’ names for the girl travelers, email addresses and phone numbers. 2. A final detailed itinerary showing travel dates, plans for each day, lodging names/locations, etc.

I have read the policies regarding troop trips/activities as stated in Safety-Activity Checkpoints and the GSSJC Resource Guide. I agree to abide by them and by any other standards that may be set in connection with this trip.

Trip Leader’s Signature: Date:

*Reminder: The Evaluation of Extended Trip (GSSJC O-927) is due immediately following the trip.



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Use this form ONLY with Girl Scout Medical Information Form (GSSJC F-185 Rev. 05/05)

GSSJC F-204M Rev. 05/05

GIRL SCOUT PERMISSION SLIP – MULTIPLE USE

Girl Scouts of San Jacinto Council (THIS FORM MAY BE PHOTOCOPIED WHEN COMPLETED. PRINT CLEARLY, USE BLACK INK.)

Girl's Name: Troop/Group # Age:

My daughter has my permission to attend the activity/activities listed below. She will not attend if she is not feeling well. I give my permission to have her treated by a licensed physician if necessary. I also agree to be financially responsible for all expenses associated with providing medical care for my child. My signature on this document also allows Girl Scouts to use photographs, voice, and/or video of my child for Public Relations purposes. My daughter may have opportunities in the future to attend activities other than the ones listed on this form. I acknowledge that if I give permission for her to participate in such activities in the future, it is under the same conditions that are set out in this form, including with respect to transportation. (Leader: Attach future parent permissions to this form.)

Leader should communicate complete information about each planned activity to parent/legal guardian, including activity, location,date/time, departure time/place, return time/place, cost, dress, what to bring, and other pertinent information.

Activity: Date:

Activity: Date:

Activity: Date:

Activity: Date:

Activity: Date:

Activity: Date:

TRANSPORTATION RELEASE: I understand that troop/group leaders must obtain the written consent of parent/guardian for every girl wishing to participate in an activity or outing that is held at a different place and time from the regularly scheduled troop/group meeting. I accept responsibility for the transportation of my child to and from any Girl Scout activity and recognize that transportation to and from Girl Scout events is not the responsibility of Girl Scouts of San Jacinto Council. I recognize that the driver of any such carpool or bus service that I arrange is not acting as an agent of Girl Scouts of San Jacinto Council. It is my expressed intention to hold Girl Scouts of San Jacinto Council harmless for any and all injuries, death or damages arising from or in any way related to any such transportation.

I give my permission for my daughter to participate in Boating, Swimming, Horseback Riding, or other strenuous activities. If no exceptions, she may participate in all activities. EXCEPTIONS:

My daughter may not be released to: __________________________________________________________________________________________________________If unable to reach me in case of an emergency or change in plans, please contact one of the following. I will make arrangements with these people prior to the event.

Name: Day:( ) Evn:( ) Relationship:

Name: Day:( ) Evn:( ) Relationship:

Medication(s) she can have: _____________________________________________________________________________________________________________

Medication(s) she cannot have:___________________________________________________________________________________________________________

Note: Any medications must be provided in original containers along with a signed note and instructions.

Signature of Parent/Legal Guardian Phone # Pager or Cell Phone Date

______________________________________________________Print Name of Parent/Legal Guardian

GIRL SCOUT INSURANCE CARRIER: MUTUAL OF OMAHA For confirmation, contact Girl Scouts of San Jacinto Council 713-292-0300 or 1-800-392-4340

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GIRL SCOUT MEDICAL INFORMATION Girl Scouts of San Jacinto Council

(THIS FORM MAY BE PHOTOCOPIED WHEN COMPLETED. PRINT CLEARLY, USE BLACK INK.)

Girl's Name Troop/Group # Phone ( )

Home Address City State Zip

Date of Birth Date of last Health Exam

Girl's Physician/Clinic Phone ( )

Parent/Legal Guardian Phone ( ) Cell Phone ( )

HOSPITAL INSURANCE INFORMATION Attach photocopy of insurance card.Name of Carrier Policy # Insured's name Member ID# Company name if insured through employer Phone: ( )

Others who could be contacted to authorize treatments:

Name Day( ) Evn( ) Relationship

Name Day( ) Evn( ) Relationship

PART I Allergies (Check those that apply. Specify cause and nature of reactions - e.g. penicillin causes hives.) __Animals __Plants __Food __ Medicine/Drugs __Hayfever __Pollen __Insect Sting __Other: In case of an allergic reaction, respond by

PART II Health Conditions (Check those that apply.) Chronic or reoccurring illness: __Asthma __Musculoskeletal Disorders __Kidney Disease __Diabetes __Heart Disease/Defects __Hypertension __Seizures __Bleeding/Clotting Disorder __Ear Infection __Other:

IN THE LAST YEAR: (ANSWER YES OR NO)Complicating medical problems/operations? Serious injury/illness requiring medical care? ____________Explain: ___________________________________________________________________________________________

SPECIFIC INSTRUCTIONS / ONGOING TREATMENTS:

PART III Other Health Conditions (Check those that apply.)

__Sleep disturbances __Motion sickness __Constipation/diarrhea __Bedwetting__Hepatitis A / B / C (circle one) __Menstrual complications __Sickle cell trait or disease __ADHD / ADD __Emotional disturbances __Hearing impairment __Special dietary regiment __Fainting__Physical disabilities __Frequent headaches __Wears contact lenses/glasses __Nosebleeds__Orthodontic appliances __Eating disorders __Other (specify) _______________________________________________________________________________________

Please explain. Indicate any information useful to the adult in charge in relation to any of the above health conditions. Indicate any activity to be encouraged or restricted __________________________________________________________________

Dietary Needs / Restrictions: ___________________________________________________________________________________

GIRL SCOUT INSURANCE CARRIER: MUTUAL OF OMAHA For confirmation, contact Girl Scouts of San Jacinto Council 713-292-0300 or 1-800-392-4340

Page 1 of 2

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PART IV

Immunization/Disease History (Please complete or attach a copy of this child’s Immunization Record)

Immunization Year Primary Series Completed Year of Last Booster Has had Disease D.T.P. DiphtheriaPertussis (whooping cough) TetanusTd (tetanus/diptheria) Measles MumpsRubella (German Measles) Chicken Pox Oral Polio HibHepatitis B Tuberculin Test Result (most recent) Other

Listed are medication(s) my child will routinely take with the supervision of the Leader/First Aider. (Attach a list if necessary.)

Medication: Dosage: How Often:

Over the Counter Medication(s):

She can have: ________________________________________________________________________________________

She cannot have: _____________________________________________________________________________________

Parent’s/Legal Guardian’s Authorization: This health history is correct so far as I know, and the person herein described has permission to engage in all planned trip activities except as noted by the examining physician or me.

TRANSPORTATION RELEASE: I authorize transportation for my child by emergency vehicle to an appropriate health care facility and pre-hospital medical care, all hospital and physician services, whether medical, surgical and/or dental, necessary for the benefit/safety/well-being of my child. It is my expressed intention to hold Girl Scouts of San Jacinto Council harmless for any and all injuries, death or damages arising from or in any way related to any such transportation.

CONSENT TO TREAT: I hereby give permission to the physician selected [by the trip coordinator] to order X-rays, routine tests and treatment for thehealth of my child, in the event I cannot be reached in an emergency. I hereby give permission to the physician selected by the first aider/trip coordinator to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for my child as named above.

The information disclosed on this form may be released to Volunteer/Staff responsible for this activity including, but not limited to troop/group leaders, drivers, medical personnel, etc.

My signature confirms that the above information is correct to the best of my knowledge and that I am authorized to execute the information form and release.

Signature of Parent/Legal Guardian Full Name of Child Relationship to Child Date

Day ( ) Evn ( ) Cell ( ) Print Name of Parent/Legal Guardian

Address City State Zip

GSSJC F-185 This form must be completed yearly or updated as needed Revised 05/05 Page 2 of 2

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National Trips: Complete by participant Attach PhotoInternational Trips: Doctor's Exam required within 6 months of Trip

ADULT HEALTH EXAMINATION FORM

Name of Applicant - Last, First, Middle Sex Date of Birth F M

Address City State Zip Code

In Emergency Notify: Name Address Phone (Area Code) ( )

Relationship

Health History-Check if you have had any of the following: Eyesight Impairment Heart Disease Arthritis Intestinal Disorders Hearing Impairment Rheumatic Fever Diabetes Chicken Pox Speech Impairment Abnormal Blood Pressure Tuberculosis Measles Disorders of Nervous System Mental or Emot. Disorders Hernia Mumps Sinusitis Disease of Ears Hayfever or Asthma German Measles Disease of Kidneys Severe Menstrual Pain Other Serious Allergies Have you been hospitalized in the last five years? Yes No Are you taking any medication? Explain If you have checked or answered yes to any of the above, give nature, dates, period of any disability and results:

I certify that to the best of my knowledge I am in good health and able to participate in this event/assignment.

Signature of Applicant Date

Medical Insurance Information:

Insurance Company Name:

Address: Phone #

Type of Coverage: Policy# Group #

Name of Insured:

Employed by: Phone #

Physician-Please complete remainder of application Instructions: Please ask applicant to show you a written description of the event/assignment so that you may determine whether she/he is in condition to participate in this particular

event/assignment and to insure that the applicant has the valid immunizations required. Examination Findings-Check box if condition is satisfactory. If not satisfactory, explain in space provided or on reverse side.

Eyes and Vision Ears and Hearing Menstrual Periods Abdomen Skin Heart Chest X-ray (if Required) Throat Lungs Legs (Camping or Primitive Conditions) Exact Measurements of:

Blood Pressure Systolic Diastolic

Pulse Rate Urinalysis SP Gravity

Sugar Albumen Height Weight

Does applicant have any condition which might limit activity for this event/assignment? Yes No Does applicant have any chronic diseases? Yes No If overweight will condition Restrict activity? Yes No Does applicant have any conditions which might limit her/his participation in swimming, hill climbing and other strenuous activities? Yes No If any of the above were unsatisfactory, or applicant has any limitations, use this space to explain.

Immunizations-Fill in date of valid immunizations applicant has had. Only those requested on the announcement of the event/assignment are required.

Immunization Date Last Received Immunization Date Last Received

Small pox Vaccination Typhoid and Paratyphoid

Tetanus Cholera

Typhus Yellow Fever

Polio-Complete Series or Booster required Gamma Globulin (Hepatitis)

Rocky Mountain Spotted Fever (entire series) Other

German Measles

Statement of Physician -Applicant is in good physical condition and able to participate in this event/assignment. - Applicant should not participate in this event for the following reasons:

Name of Physician Signature Address

Health History at Event/Assignment: SJGS O-905 Rev. 1/94

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GUARDIAN'S PERMISSION FOR DAUGHTER TO TRAVEL AND POWER OF ATTORNEY FOR LEADERS OF TRAVELING TROOPS/GROUPS

GIRL SCOUTS OF SAN JACINTO COUNCIL

STATE OF TEXAS COUNTY OF

BEFORE ME, the undersigned authority, on this day personally appeared

, known to me to be the person whose name is subscribed to this instrument; and who, after being by me first duly sworn, depose and say:

My name is . I am over 18 years of age and competent (Guardian)

to make this affidavit of permission and power of attorney. I am the natural Legal Guardian of

, age years, has my permission to accompany

and (adult in charge) (adult in charge)

and Girl Scout Troop/Group # to .

Also, and have my permission and are authorized to act on my behalf and in my place during the trip to authorize any medical or surgical emergency treatment or make decisions concerning any other matters which such persons feel require an immediate decision and hereby state that it is my expressed intent to release Girl Scouts of San Jacinto Council, the above named individuals and Girl Scout Troop/Group # from any liability or damages which might be claimed because of the actions taken by or omissions by them due to premises defects or maintenance, or acts of third parties beyond their control.

GUARDIAN'S LEGAL SIGNATURE

SWORN TO AND SUBSCRIBED BEFORE ME

THIS DAY OF , 20

NOTARY PUBLIC IN AND FOR

COUNTY, TEXAS

My commission expires

GSSJC F-318 Rev. 3/01

32

GIRL SCOUTS OF SAN JACINTO COUNCIL POWER OF ATTORNEY FOR ADULT TRAVEL

STATE OF TEXAS COUNTY OF____________________________________

BEFORE ME, the undersigned authority, on this day personally appeared

___________________________________, known to me to be the person whose name is subscribed to this instrument; and who, after being by me first duly sworn, depose and say:

My name is _________________________________. I am over 18 years of age and competent to make this affidavit of permission and power of attorney to cover the following trip.

Destination:_____________________________ Dates:__________________________

In the event that I am unable to give my personal consent, I give my permission and authorize the following persons, _________________________________ and _____________________________________ to act on my behalf to authorize any medical or surgical emergency treatment of make decisions concerning any other matters which such persons feel require an immediate decision; and hereby state that it is my expressed intent to release Girl Scouts of San Jacinto Council, the above named individuals and Girl Scout Troop/Group # __________ from any liability or damages which might be claimed because of the actions taken by or omissions by them due to premises defects or maintenance, or acts of third parties beyond their control.

It is understood that all efforts will be made to notify my designated “person to be contacted in an emergency

_______________________________________________Signature

SWORN TO AND SUBSCRIBED BEFORE ME

THIS ___________ DAY OF _________________, 20___

________________________________________________NOTARY PUBLIC IN AND FOR

_____________________________ COUNTY, TEXAS

My commission expires _____________________________

GSSJC O-906 Rev. 7/07

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GSSJC O-903 11/07

GIRL AGREEMENT FORM FOR GIRL SCOUTS PARTICIPATING IN AN COUNCIL PLANNED TRIP

I understand my attitude and behavior are critical to the success of the trip. Therefore, for the good of the trip as well as my fellow group members, I agree to abide by the following:

1. I will try to be sensitive to the needs of each group member.

2. I will be cooperative and abide by the group decisions.

3. I will respect the places and the people with whom I come in contact.

4. I will attend scheduled meetings and work with leaders on all phases of planning and preparing for the trip.

5. I will be responsible for my personal belongings and equipment and will not hold Girl Scouts of San Jacinto Council, Inc. responsible for their loss or damage due to my negligence or neglect.

6. I will treat all equipment provided for my use with care. I understand that I will be assessed for damages to any equipment in the event that my use of such equipment is negligent or abusive.

7. I will use all required safety equipment and follow safety rules and procedures, i.e. buddy system.

8. I agree to take my share of daily responsibilities, such as being on time and keeping my motel/hotel room neat and clean.

9. I understand that the use of firearms, tobacco, alcohol, or drugs will not be tolerated, and that usage during the trip will result in expulsion from the trip.

10. I understand that if I am sent home early due to any serious misconduct, it will be at my parent’s or guardian’s expense and that Council Staff may make the travel arrangements and notify my parent or guardian of those plans.

11. I will complete and return the trip evaluation.

12. I will complete all pre-trip requirements and have the necessary clothing and equipment.

_____________________________________ _________________Participant’s Signature Date

I understand and agree with the above responsibilities of my daughter.

_____________________________________ _________________Parent or Guardian’s Signature Date

34

ADULT AGREEMENT FORM

For Leaders and/or adults accompanying or supervising Girl Scouts participating in a trip

I understand as a Leader or adult member of Troop/Group # _________, I play an essential role in the success of this trip and that my attitudes, behavior and responsibilities as a role model are critical to the success of the trip to ____________________________.

I, therefore, agree to do the following:

1. Be sensitive to the needs of each participant. 2. Be flexible, cooperative and abide by group decisions. 3. Respect the places and the people with whom I come in contact. 4. Work with the Trip Coordinator on all phases of planning and preparing for the trip. 5. Attend scheduled meetings and review and become familiar with all the materials and

forms provided for this trip in order to interpret them to girls and their families. To see that all-appropriate forms are completed.

6. Adhere to and follow GSUSA’s and Girl Scouts of San Jacinto Council’s health and safety standards during all phases of the trip. (See Safety-Wise & Resource Guide)

7. Carry out “adults only” responsibilities during the trip. 8. Understand the use of firearms, alcohol, or drugs will not be tolerated and that usage

during the event will result in expulsion from the event. 9. Be responsible for my personal belongings and equipment and will not hold Girl Scouts

of San Jacinto Council, Inc. responsible for their loss or damage due to my negligence or neglect.

10. Treat equipment and supplies with care. I understand that I will be assessed for damages to any equipment in the event that my use of such equipment is negligent or abusive.

11. Use all required safety equipment and follow agreed-upon safety rules and procedures, i.e. buddy system, two adults with girls while on hikes, etc.

12. I understand that if I am dismissed due to any serious misconduct, it will be at my expense and that Girl Scouts of San Jacinto Council staff may assist in making the travel arrangements.

13. Complete and return the trip evaluation. 14. Ensure our group has completed all pre-trip requirements and has the necessary

clothing and equipment. 15. Provide supervision to our group throughout the trip. 16. Should unavoidable circumstances prevent my going on the trip, I will provide a “stand-

in” adult to go in my place to provide the adequate adult/girl ratio, if necessary.

After completion of this agreement collect statements from girls. Trip coordinator will collect all forms.

__________________________________ ______________ Signature Date

GSSJC 0-904 11/07

35


EVALUATION

Extended Troop / Group Trips Troop/Group # Jr Cad Sr Amb Service Unit

(5 nights or more) Trip Destination Trip Dates

DUE 2 WEEKS AFTER TRIP


Leader / Advisor’s Name: Phone Address

Street City Zip Code Email Address: Number of girls in the troop/group: Number of girls who went on the trip: Number of adults who went on the trip: Women Men

1. Actual Itinerary (Attach a separate sheet)

2. Program Activities (Attach a separate sheet)

3. Program Highlights What was the greatest benefit to individuals and the troop from this project?

What was the most difficult or least beneficial?

4. Was the troop’s preparation appropriate for what they did? ___yes ___no If yes, what pre-planning was especially helpful? If no, what would the girls recommend changing or adding?

5. Were there areas which could have been better planned? Things you would do differently? (accommodations, financing, transportation, activities, etc?) ___yes ___no If yes, what?

6. Did the girls feel the trip was worth the effort? ___yes ___no Did the adults? ___yes ___no If not, please explain:

7. List the ways parents were involved in the trip:

36


Finances (or attach your own financial records)

Budget Estimated Amount Actual Expense

Transportation Lodging Food Sightseeing Insurance Emergency Fund Other* (Please list “Other” expenses below, i.e. postage, reservation fees, maps, books, etc.)

TOTAL:

*Other Expenses:

Average spent per girl Amount provided by each girl Amount provided by troop/group Other

If there is a major difference between what was anticipated and what was spent, please comment on the cause:

Were there any emergencies on the trip? If yes, please explain:

Did you contact the Extended Troop/Group Trip Coordinator for any help during the planning sessions? If yes, was she helpful?

Please attach suggestions for additional ways Council could assist girls in preparation for a trip.

Will the troop/group plan another trip soon? ___yes ___no If so, where? What one suggestion would you give other groups traveling?

What one suggestion would you give other leaders traveling?

Troop/Group Leader’s Signature: Date:

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Trip Coordinator

41

Trip Coordinator

42

trip coordinator postmarked no

46

Trip Coordinator

48

Trip Coordinator

4

49

of 4

50

of 4

51

of 4

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of 4

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6. If you travelled through the US, what states id you visit as part of this trip?

7. If you travelled out of the country, what country or countries did you visit as part of this trip?

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Please indicate the name of the agency you used and give them an overall service rating on a scale of 1 to 5, where 1 is Very Poor and 5 is Excellent.

18.

60

19.

20.

21.

22.

23.

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25.

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28.

64

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