ࡱ> @ PsbjbjFF u,,j ---8 ..dNhh/4^t4t4t470;\>0MMMMMMM$^PRRdMA0747^AAMt4t4NHHHARt4H8t4MHAMHHrLT&"Lt4\/ `/ 7-BBULaMlN0NcL2SCSLSLN??^H0@L|@2N?N?N?MMPG"PCouncil approval is required for Girl Scout troops/groups doing activities that include travel farther than 75 miles from regular meeting place and/or overnight travel or camping. Instructions Consult Safety-Wise for the specific and universal checkpoints for basic guidelines and Girl Scout Program Standards to ensure that at all times the health, safety, and security of your group is being practiced. For activities with no checkpoints, you will need to check with your field executive and utilize the Universal Checkpoint section in Safety-Wise to determine if the activity is suitable and safe for your group. Complete the following approval request form and return it to your field executive at the address listed below three weeks prior to travel. Obtain written permission forms from a parent or legal guardian before departure. You will be notified of the status of your request. * Use the Site Reservation Request Form to reserve council owned/operated facilities. SECTION A GIRL SCOUT TROOP/GROUP INFORMATION Troop/Group #  FORMTEXT       Service Unit:  FORMTEXT       Troop/Group Age Level:  FORMCHECKBOX  Daisy  FORMCHECKBOX  Brownie  FORMCHECKBOX  Junior  FORMCHECKBOX  Teen Girl Scout 11-17 Name of Troop/Group Leader(s) who have attended Leader Orientation and Age Level Training:  FORMTEXT       Anticipated Number of Participants in this activity: Girls:  FORMTEXT       Adults  FORMTEXT       Leader/Trip Coordinator:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip  FORMTEXT       Phone: (H)  FORMTEXT       (W)  FORMTEXT       E-mail Address:  FORMTEXT       Cell Phone (Optional):  FORMTEXT       Best time and way to be reached:  FORMTEXT       SECTION B TRAVEL INFORMATION Date of Travel: From  FORMTEXT       To  FORMTEXT       Destination:  FORMTEXT       Brief description of activity(ies)girls will be engaged in  FORMTEXT       Mode of Transportation:  FORMTEXT       * * All contracts (i.e. rental agreements, etc.) must be signed by the Executive Director/CEO. Please allow a minimum of 72 hours. Charter vehicles must have a certificate of insurance on file at the Girl Scout Service Center. Travel Planning and Preparation Checklist We have:  FORMCHECKBOX  Reviewed the specific activity checkpoints for this trip, or sought advice from our field executive because the activity was not listed in the activity checkpoints in Safety-Wise.  FORMCHECKBOX  Reviewed the procedures and guidelines and tips on trip planning in Safety-Wise.  FORMCHECKBOX  Made realistic, detailed plans and budget. Personal and group expenses have been defined.  FORMCHECKBOX  Established group conduct expectations and safety precautions and procedures.  FORMCHECKBOX  Confirmed the participation of the proper number of adult chaperones who have accepted the responsibilities of this trip.  FORMCHECKBOX  For trips of three nights or more, obtained insurance coverage for the entire trip through the council.  FORMCHECKBOX  Followed council procedures for getting contracts signed and chartering, renting or borrowing vehicles. (See Council Guide)  FORMCHECKBOX  Provided a copy of the councils Major Emergency Procedures card to each adult chaperone.  FORMCHECKBOX  Our complete, written itinerary, including telephone numbers and addresses will be given to the girls, their families, our field executive, and the emergency contact person prior to departure. If camping on an other than council owned site, please provide the following information: Name of Site:  FORMTEXT       Address  FORMTEXT       Phone  FORMTEXT       Who operates the site?  FORMTEXT       Is it licensed by the city/state?  FORMTEXT       Does the council have insurance information on the site?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you visited the site?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If so, please check all that apply:  FORMCHECKBOX  Safe Drinking Water.  FORMCHECKBOX  1 toilet/20 campers with handwashing facilities.  FORMCHECKBOX  Separate sleeping accommodations and bathroom available for men if attending.  FORMCHECKBOX  No hazardous or potentially dangerous areas nearby. Documentation of Required Certifications: Note all that apply to your outing. (See Safety-Wise) This outing requires a  FORMCHECKBOX  Level I or  FORMCHECKBOX  Level II Certified First Aider. Our First Aider is:  FORMTEXT       Other:  FORMTEXT       Please submit copies of documentation along with this form. Documentation of Trained, Qualified Adult Supervision Camping: Please check which description best matches your camping plans and note who has attended at least the minimum appropriate training.  FORMCHECKBOX  We will be sleeping indoors, and using an indoor kitchen (stove/oven) to prepare all of our food. There will be no fire building or outdoor cooking.  FORMCHECKBOX  We will be sleeping indoors, but we will be making a campfire and/or cooking some meals outside over an open fire. Minimum Training Option: Group Camping 102. Trained adult  FORMTEXT        FORMCHECKBOX  We will be sleeping in tents, or using a facility where the sleeping area, kitchen/dining area, and bathrooms are detached, and/or we will be having a campfire or cooking at least some of our meals outside over an open fire. Minimum Training Option: Group Camping 105. Trained adult  FORMTEXT       If the person teaching and supervising the experience has comparable experience or training, they should submit the Adult Camping Comparable Experience Verification form available at the Girl Scout Service Center. Traveling Troop: List name and phone # of adult who has attended one of our Girl Scout Traveling Troop training sessions:  FORMTEXT       Adult Drivers: Our council requires that adults transporting girls in private or rented cars/vans should be age 21 or older. They should be properly licensed and carry at least the minimum insurance as required by the state. 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FORMTEXT       Name (as it appears on driver s license):  FORMTEXT       State of Issue  FORMTEXT       Driver s License #  FORMTEXT       Name of Auto Insurance Co.  FORMTEXT       Name (as it appears on driver s license):  FORMTEXT       State of Issue  FORMTEXT       Driver s License #  FORMTEXT       Name of Auto Insurance Co.  FORMTEXT       BACK HOME EMERGENCY CONTACT The following person will know where our troop is during our travel and is the person who should be contacted in case of emergency: Name  FORMTEXT       Phone (H)  FORMTEXT       (W)  FORMTEXT       Cell  FORMTEXT       Address:  FORMTEXT       The information provided above is true and as complete as is possible at this time. I understand that I will need to submit any missing required documentation to the council, and that I must obtain written parent permission prior to departure. We have received Leader Orientation and Age Level Training and are taking steps to involve girls in the planning. We agree that we will strive to meet the program, health, safety and security guidelines as written in Safety-Wise, and abide by Girl Scout policies. Signature of Girl Scout Leader/Trip Coordinator  FORMTEXT       Date  FORMTEXT       Typing your name here qualifies as a valid signature COUNCIL USE Date received: Log of Communication about Outstanding Information: Additional Comments: Date Approved: and mailed back to Girl Scout leader/trip coordinator. Date Approval Notification/Documentation forwarded to Council Owned Site Reservation Desk: Field Executive s Signature 05/07 Web  Word Document Template Page  PAGE 3 of  NUMPAGES 3 Girl Scout Council of the Mid-South   Traveling Troop/Camping Approval Request Form*  Mailing Address: P. O. 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