ࡱ> '` bjbj )nnnn2 2 2 F GGG8GJF v("MbLfbfbfbfdjx $hd2 e"e^nnfbfb 0nRfb8fbV-@" fbM P'˽,G9m l F0vy jjj2 X:T|А vF F F :CF F F CF F F nnnnnn Please select distance of travel below:  FORMCHECKBOX  0-75 miles away from regular meeting place, including overnight and day trips (Return form to Membership Manager 10 days prior to trip)  FORMCHECKBOX  75-250 miles away from regular meeting place, including overnight and day trips (Return form to Membership Manager 1 month prior to trip)  FORMCHECKBOX  250 miles or more from regular troop meeting place and/or longer than 2 nights (Return form to Membership Manager 2 months prior to trip) For Trips longer than 2 nights, additional insurance is required and needs to be purchased through the council. Please see the Additional Insurance Request Form for more information. Please attach proof of insurance and copy of each drivers license for each vehicle if providing transportation for the troop. Please fill out all applicable sections completely for proper travel approval. Troop Information Service Unit:  FORMTEXT       Age Level  FORMTEXT       Troop #  FORMTEXT       Leader/Trip Coordinator:  FORMTEXT       E-mail:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       Phone: (H)  FORMTEXT       (W)  FORMTEXT       Cell  FORMTEXT       Travel Dates/Times Departing on: Day of week  FORMTEXT       Date  FORMTEXT       at (time)  FORMTEXT        FORMCHECKBOX  AM or  FORMCHECKBOX  PM Departing from: Name of location/Street Address  FORMTEXT       City  FORMTEXT       State FORMTEXT       Returning on: Day of week  FORMTEXT       Date  FORMTEXT       at (time)  FORMTEXT        FORMCHECKBOX  AM or  FORMCHECKBOX  PM Returning from: Name of location/Street Address  FORMTEXT       City  FORMTEXT       State FORMTEXT       Primary Geographic Destination Name of Area  FORMTEXT       County  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Type of Facilities  FORMCHECKBOX  Theme Park  FORMCHECKBOX  State Park  FORMCHECKBOX  National Park  FORMCHECKBOX  Museum  FORMCHECKBOX  Aquarium   FORMCHECKBOX  Horses  FORMCHECKBOX  Recreation  FORMCHECKBOX  Water/Swim  FORMCHECKBOX  Zoo  FORMCHECKBOX  Skating  FORMCHECKBOX  Bowling  FORMCHECKBOX  Movies  FORMCHECKBOX  Other  FORMTEXT        FORMCHECKBOX  Other  FORMTEXT       *Note: Please attach an itinerary if going to multiple locations. Number of ParticipantsYouth (under age 18)Adult (over age 18)FemaleMaleFemaleMaleTotalRegistered with your troop FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      NOT registered with your troop FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Emergency Contact Person (who will not be on the trip) Name  FORMTEXT       Relation to troop  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       Phone: (H)  FORMTEXT       (W)  FORMTEXT       Cell  FORMTEXT       Sleeping Accommodations Name of Facility  FORMTEXT       Dates Used  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       On Site Phone  FORMTEXT       On Site Contact  FORMTEXT       Type of Lodging (please check one)  FORMCHECKBOX  Tent  FORMCHECKBOX  Home  FORMCHECKBOX  Cabin/Lodge  FORMCHECKBOX Hotel/Motel  FORMCHECKBOX  Other  FORMTEXT       Note: Per GSUSA policy, separate sleeping quarters and bathroom facilities must be provided for any males in attendance. Type of Transportation and Drivers All drivers must fill out a Driver and Vehicle Information Form and return it to the troop leader for their records. Privately Owned Vehicles (Please list the number of each type to be used.)  FORMCHECKBOX  Automobile  FORMCHECKBOX  Bus Other (give full description of the vehicle)  FORMTEXT       Leased/Rented Vehicles (Please list the number of each type to be used.)  FORMCHECKBOX  Automobile  FORMCHECKBOX  Bus Other (give full description of the vehicle)  FORMTEXT       *Leased/rented from  FORMTEXT       Phone  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Note: Leased/rented vehicle contracts must be signed by GSHS CEO before departure, please allow at least 2 weeks to process. Driver(s) Name & License No.Attached copy of license and current insurance (Yes or No)Filled out Driver and Vehicle Form (Yes or No)Registered Girl Scout (Yes or No) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Trained Adults with Troop (Insert date trained. Specify  Other skills.) At least one certified First Aider (trained in CPR and First Aid) and a first aid kit must be present at all times during trip. Person with Certified Training*First Aid*CPR**Event Camp License (ECL)**Troop Camp License (TCL)Advance Backpacking License (ABL) Archery Small Craft SafetyLife GuardOther FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      *Required for any troop trip **Required for any outdoor camping such as troop camping, a camporee, or council event camping. See travel guidelines for more information. Consultants or Resource Personnel at Utilized Facilities (Specify Other Skills needed or utilized) Facility NameConsultants Name (if known)Outdoor SkillsFirst AidLife GuardSmall CraftOther SkillsEx: Smoky Bear ParkJim JamesYesYesArchery FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTE()789:Npy乮teZEeZ)jvha]h`R5>*CJU^Jha]5>*CJ^Jjha]5>*CJU^Jhyhy5OJQJ^Jha]5OJQJ^Jhy5OJQJ^JhyV5>*CJ^Jhy5>*CJ^Jhvc5>*CJ^JhN5>*CJ^J)jha]h`R5>*U^JaJha]5>*^JaJjha]5>*U^JaJh(h8>*CJ^J(& ` 5 6 - (#+$d%d&d'dNOPQgdNgdU$a$gd8`gd3s`gd(gdygd(gd~nXv  $ % & _ ` a o p q r 䵩n`WKhyh~n>*CJ^JhW7>*CJ^Jh(h3s5>*CJ^J)jha]h`R5>*CJU^Jha]5>*CJ^Jjha]5>*CJU^JhyhJJ>*CJ^Jhyh8>*CJ^Jh(5>*CJ^JhyV5>*CJ^Jh(hg5>*CJ^Jhvc5>*CJ^Jh(h85>*CJ^Jh(h~n5>*CJ^J ' ( / ? m x | } 3 5 6 = A B F ^ h t z ␉ung`Y`Oh}hv>*CJ h>*CJ hB>*CJ hy>*CJ hvc>*CJh}h}>*CJh}hB>*CJ h3s>*CJ hN>*CJhVOJQJ^J ha]h8CJ OJQJ^JaJ hh86OJQJ^Jhyh86OJQJ^Jh$@eOJQJ^Jh3sOJQJ^Jh8h8OJQJ^J ha]h(CJ OJQJ^JaJ   " $ 8 : < F H J X Z \ p r t ~ ĻĻrĻ^Rht Vhv>*OJQJ&jJht Vh0>*OJQJU&jht Vh0>*OJQJU%jht V>*OJQJUmHnHu&jbht Vh0>*OJQJUjht V>*OJQJUht V>*OJQJht VOJQJhvOJQJhvhUCJOJQJaJ#h}h}5CJOJQJ^JaJhvhvCJaJ  pB- +@@@$d%d&d'dNOPQgdt V1 $+@@@@P$d%d&d'dNOPQgdt V. +P$d%d&d'dNOPQgdt V/ (#+P$d%d&d'dNOPQgdt V        ( * , @ B D N P R \ ^ ` t v x ٲٲ~ٲjٲ&jht Vh0>*OJQJU&jht Vh0>*OJQJUht Vhv>*OJQJ&j2ht Vh0>*OJQJU%jht V>*OJQJUmHnHu&jht Vh0>*OJQJUjht V>*OJQJUht V>*OJQJht VOJQJhvOJQJ)  *,.468LNPZ\^fhj~}i&jht Vh0>*OJQJU&jvht Vh0>*OJQJUhUOJQJht Vhv>*OJQJ&jht Vh0>*OJQJUht VOJQJ%jht V>*OJQJUmHnHujht V>*OJQJU&jht Vh0>*OJQJUht V>*OJQJ'~  ¶tmdWdDW1$jht V5>*CJUmHnHu%jht Vh05>*CJUjht V5>*CJUht V5>*CJ ht V5CJ#h3shU5CJOJQJ^JaJ#h3sh3s5CJOJQJ^JaJh]&hvCJ OJQJaJ hvhvCJOJQJaJht Vhv>*OJQJht V>*OJQJ%jht V>*OJQJUmHnHujht V>*OJQJU&jbht Vh0>*OJQJUyF2$ `'+P$d%d&d'dNOPQa$gdt V0$ H $$d%d&d'dNOPQa$gdt V#$d%d&d'dNOPQgdU$a$&$d%d&d'dNOPQgdN$&(<>@JLN`bdxz|BDFZ\^h閵r_%j" ht Vh05>*CJU"jhih3s5CJU"j:hih3s5CJUjh3s5CJU%jht Vh05>*CJU h3s5CJ$jht V5>*CJUmHnHu%jNht Vh05>*CJU ht V5CJht V5>*CJjht V5>*CJU%hjltvx *,.68:NPR\^`rtvwp h3s5CJ%j ht Vh05>*CJU%j ht Vh05>*CJUht Vh3s5>*CJ%j ht Vh05>*CJU$jht V5>*CJUmHnHu%j ht Vh05>*CJU ht V5CJht V5>*CJjht V5>*CJU*TVXlnpz|~÷rÅ_Å%jD ht Vh05>*CJU%j ht Vh05>*CJU ht V5CJ"jZ hih3s5CJU"j hih3s5CJU h3s5CJjh3s5CJUht V5>*CJ$jht V5>*CJUmHnHujht V5>*CJU%jp ht Vh05>*CJU$&h`X$a$gd3s$a$gd 0$ `'+$d%d&d'dNOPQa$gda]2$ `'+P$d%d&d'dNOPQa$gdt V2$ H $P$d%d&d'dNOPQa$gdt V$&(@BDXZ\fhjlxz|÷}vc÷vPv%jht Vh05>*CJU%j0ht Vh05>*CJU ht V5CJhvh5CJaJhRCh@<CJaJhRCh3sCJaJh]&h5CJ aJ ha]ha]5CJaJht Vh3s5>*CJht V5>*CJ$jht V5>*CJUmHnHujht V5>*CJU%j ht Vh05>*CJU&(l LVo995$ px<$P$d%d&d'dNOPQa$gd3s2$ $+P$d%d&d'dNOPQa$gdt V-$ +$d%d&d'dNOPQa$gdt V/$ P+$d%d&d'dNOPQa$gd 02NPRjlunbnPbnbn"jhRCh3s5CJUjh3s5CJU h3s5CJh0h3s5>*CJ$jh05>*CJUmHnHu%jh0h05>*CJUjh05>*CJUh05>*CJ h05CJ$jht V5>*CJUmHnHu%jht Vh05>*CJUjht V5>*CJUht V5>*CJ468LNPRnpr۷ۥ۔ۂp^"j4hRCh3s5CJU"jhRCh3s5CJU"jLhRCh3s5CJU!jh3s5CJUmHnHu"jhRCh3s5CJU"jdhRCh3s5CJU"jhRCh3s5CJU h3s5CJjh3s5CJU"j|hRCh3s5CJU$"$@BDXZvxzڋubuO$jh05>*CJUmHnHu%jh0h05>*CJUjh05>*CJUh05>*CJ h05CJ"jhRCh3s5CJU"j hRCh3s5CJU"jhRCh3s5CJU"j hRCh3s5CJUjh3s5CJU"jhRCh3s5CJU h3s5CJ68:FHJ^`blnprt(z|ֽ鋀ui]RIB hQx5CJhQxhQxCJhQxhQxCJaJh]&h5CJ aJ hvh5CJaJhNhNCJaJhNh@<CJaJh0h3s5>*CJ$jh05>*CJUmHnHu%jh0h05>*CJU h05CJ"jnhRCh3s5CJUjh3s5CJU h3s5CJh05>*CJjh05>*CJUVr(Rz|g_SJJS $IfgdQx $$Ifa$gd $a$gd /$ P+$d%d&d'dNOPQa$gd2 px !+P$d%d&d'dNOPQgdN5$ px !+P$d%d&d'dNOPQa$gd0|~`TKKKKK $Ifgd $$Ifa$gd kdZ$$Ifl\($-@   t0-44 la|~  246@BDFZ\^hjln۱ԟ۱ԍ۱{۱i۱"j<h0h05CJU"jh0h05CJU"jPh0h05CJU"jh0h05CJU!jh05CJUmHnHu"jdh0h05CJU h05CJjh05CJU hQx5CJ h5 h5CJ hQx5'D:.%% $Ifgd $$Ifa$gd kd$$Iflֈ#($-@ t0-44 laDl1kd$$Iflֈ#($-@ t0-44 la $Ifgd "$&:<>HJLNbdfprtvwrfhvh%#5CJaJ hQx5"jh0h05CJU"jh0h05CJU"jh0h05CJU"jh0h05CJU!jh05CJUmHnHu"j.h0h05CJU h05CJjh05CJU hQx5CJhQx'$Lt $Ifgd $$Ifa$gd :+#$a$gda]$ H $a$gda]kd|$$Iflֈ#($-@ t0-44 la8@BDXZ\fhj׵ɢך׆ɢzfɢ&jh0h0>*OJQJUh0h@<>*OJQJ&jnh0h0>*OJQJUh@<OJQJ%jh0>*OJQJUmHnHu&jh0h0>*OJQJUjh0>*OJQJUh0>*OJQJh0OJQJhNh@<CJaJhvhi5CJaJ"824j63$ px !+$d%d&d'dNOPQa$gdv- +@@@$d%d&d'dNOPQgd01 $+@@@@P$d%d&d'dNOPQgd0. 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$$Ifa$gd0f7h7j7t7v7x7z77777777777777777777778սլ՞սլ՞nսլ՞Vսլ՞TU/j"Wh0h0CJOJQJU^JaJ/jVh0h0CJOJQJU^JaJ/j2Vh0h0CJOJQJU^JaJh0CJOJQJ^JaJ h]&huPCJOJQJ^JaJ.jh0CJOJQJU^JaJmHnHu#jh0CJOJQJU^JaJ/jUh0h0CJOJQJU^JaJXT       Other Organizations/Groups Involved or in Attendance Name of Organization# Girls# Boys# AdultsTotal FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       For Council Use Only Date Received Received By Participant s List Complete?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Contracts/Leases # Y A Troop Trip Itinerary Complete?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Male Participants # Y A Girl Scout Additional Insurance Application Filed/Paid (if applicable)  FORMCHECKBOX  Yes (Date Sent to Mutual of Omaha __________)  FORMCHECKBOX  No Approved Membership Manager Date Confirmation of Approval Sent by: Date Notes: Troop Trip Participant Information Please print Participant NameYouth or AdultMale or FemaleRegistered Girl Scout Yes or NoEmergency Contact NamePhone # with Area CodeRelationship to Participant1 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      2 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      3 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      4 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      5 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      6 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      7 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      8 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      9 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      10 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      11 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      12 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      13 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      14 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      15 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      16 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      17 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      18 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      19 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      20 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Wireless Telephone Numbers on trip Name of Adult with phone  FORMTEXT       Number with Area Code  FORMTEXT       Name of Adult with phone  FORMTEXT       Number with Area Code  FORMTEXT       Copy and use additional pages if necessary.     Page  PAGE 2 of  NUMPAGES 3 Girl Scouts Heart of the South  Troop Travel Form Required for all trips, troop camping, and overnights.  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 Greenwood, MS  662-453-2034(FAX: 662-453-2035(305 East Washington Street, Greenwood, MS 38935(Mailing: P. O. Box 1816, Greenwood, MS 38935 Jackson, TN  731-668-1122(FAX: 731-661-0011(1007 Old Humboldt Road, Jackson, TN 38305 Memphis, TN  901-767-1440 or 800-727-8104(FAX: 901-797-2183(2715 Kirby Pkwy,Ste 1, Mphs, TN 38119(Mailing: PO Box 240246, Memphis, TN 38124 Tupelo, MS  662-844-7577 or 800-624-4185(FAX: 662-680-3164(1800 W. Main St., Tupelo, MS 38801(Mailing: P.O. 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