ࡱ> kmj'` *6bjbj{P{P |t::y PPP8l$ (($6`'''''''$)hH,(]#lp^##(r(&&&#|8'&#'&&h@& 0:P#p&{'t(0(&,o$,&,& &< u   ((%   (####   DP   P    Additional Girl Scout insurance and special permission from the council office is required for any group planning an event or activity for more than 150 people. Additional Girl Scout Accident and Illness insurance is required for a troop/group participating in a trip event for more than two consecutive nights. Return this form with payment no later than sixty days prior to date of trip or event to: Girl Scouts Heart of the South P. O. Box 240246, Memphis, TN 38124-0246 Additional Insurance Purchase Form Event Coordinator s Name  FORMTEXT       Troop/Group #  FORMTEXT       Service Unit  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Home Phone  FORMTEXT       Work Phone  FORMTEXT       Email Address  FORMTEXT       Leader s Name  FORMTEXT       Trip/Event Information: Destination  FORMTEXT       Beginning Date  FORMTEXT       Ending Date  FORMTEXT       Accident-Only Coverage  (Plan 2) Number of Participants  FORMTEXT       X Number of Days  FORMTEXT       X $ .11 = $  FORMTEXT       * Accident and Sickness Coverage  (Plan 3E) Number of Participants  FORMTEXT       X Number of Days  FORMTEXT       X $ .29 = $  FORMTEXT       * Non-Member Coverage  (Plan 3P) Number of Participants  FORMTEXT       X Number of Days  FORMTEXT       X $ .70 = $  FORMTEXT       * *Minimum premium is $5.00 Make check for total amount payable to Girl Scouts Heart of the South and mail to: Girl Scouts Heart of the South P. O. Box 240246 Memphis, TN 38124-0246     Girl Scouts Heart of the South   Additional Insurance Request Form  Regional Service Centers Columbus, MS 662-328-1930(FAX: 662-328-1220(321 7th Street North, Columbus, MS 39701(Mailing: P. O. Box 2492, Columbus, MS 39704 Corinth, MS 662-287-8321(FAX: 662-286-8142(718 Taylor Street, Corinth, MS 38834( Mailing:P. O. Box 1145, Corinth, MS 38835 Grenada, MS 662-226-9 :  4 8 : N P R \ ^ ` b Ͽw_wHw8hphN >*CJOJQJaJ-jhp>*CJOJQJUaJmHnHu.jhphu>*CJOJQJUaJ"jhp>*CJOJQJUaJhp>*CJOJQJaJhN CJOJQJaJh03h035CJOJQJaJh 45CJOJQJaJhZzh 45CJOJQJaJhN hN 5CJOJQJh 2hN CJOJQJaJh 4CJOJQJhN CJOJQJ9 :  b . 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