IN PERSON REGISTRATION: 6-8 PM, AUGUST 23 & 25, 2017 Bass Pro Shops, Bass Pro Dr, Independence, MO 64055

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1 REGISTRATION PACKET Zombie Campout: Emergency Preparedness Weekend Event October 6th at 6pm to October 8th at 2:30pm This event will focus on emergency preparedness through the pop culture focus on the Zombie Apocalypse. Event Description: A first glance at the programs and activities. Survival Tools: Make a leather craft, walking stick and paracord accessories. Bring your walking stick from past years to decorate it with new items. Food & Fire: Learn to start fires with and without matches, and cook outdoors Survival Hike: Use GPS to find the important things you need to survive a zombie apocalypse. Learn how to use GPS navigation and other clues to find the 10 things your team needs to survive. Adventure Programs: Archery, Zipline, Sling Shot and Rappel Tower. ($17.00 Charge) Zombie Parade: There will be two parades. Dress up like a zombie and be part of the fashion show. There will be one for those girls that want a no-scare event. There will be a parade for those that are wanting to be more zombified. Additional programs for the two-day program will be coming, including night-time activities. Event Guidelines: This event is designed to encourage independence and self-sufficiency in girls. Adults will be assigned## responsibilities to help with programs or other event tasks. If you come, please plan to work. Girls will be## assigned to daytime units based upon challenge activity, then troop, then age. At night, you will sleep with## your troops. Troops must maintain adult to girl ratios but can combine troops to achieve the ratio, if needed. Additional## adults may be limited if we reach capacity. Juniors 2 to 20, Cadettes & up 2 to 24. Bank Transfer Details: Routing #: Account #: Bank ID: ZC605 All mailed in registrations must be POSTMARKED by 09/1/17. Girls will be placed in teams based on challenge activities choices, troops, and age. A maximum of 350 can register. No siblings or other tags are allowed. At least 1 Troop Adult MUST HAVE CAMPING 102 & First Aid/CPR/AED training IN PERSON REGISTRATION: 6-8 PM, AUGUST 23 & 25, 2017 Bass Pro Shops, Bass Pro Dr, Independence, MO 64055

2 REGISTRATION CHECKLIST: REGISTRATION SUMMARY Return this form with registration paperwork and payment. Registration Summary Girl Registration, Health History, & Permission Slip Adult Registration, Health History & Permission Slip Cash, Check, Money Order or Copy of Bank Transfer Troop Summary Pages TROOP LEADER NAME: PHONE: Troop # SU # LEVEL: JR CD SR AM GRADE: ADDRESS: Overnight Accommodations: Please choose one. (Troops limited to adult ratios for age levels) My troop will tent camp. (Must provide your own tents) My troop will sleep in perma-tents. (Limited number of perma-tents available.) Girl Registration $ X Number of Girls Totals Adult Registration $25.00 X Number of Adults Totals Challenge Activity * $17.00 X Number of Girls Totals (Limited to 240 girls only) Bus Riding $10 (Required) X Number of Girls Totals Zombie T-Shirt $10 X Number of Girls/Adults Totals (See order sheet for details) TOTAL REGISTERED TOTAL $ Paid by (check one): CASH CHECK MONEY ORDER BANK TRANSFER (COPY REQUIRED WITH REGISTRATION)

3 GIRL REGISTRATION & HEALTH HISTORY Girl s Name: Troop # SU Troop Level: (heck One) JR CD SR AM GRADE LEVEL Troop Leader: Parent/Guardian: Primary Phone: Parent Parent Address: My daughter made a walking stick at last year s event and will bring it for Walking Sticks II. This is a traditional part of the event. My daughter will make a walking stick in Walking Sticks I Yes No My daughter will participate in a challenge activity, which is a $17 fee in addition to the basic registration. If you marked yes, please rate options from 1 (highest) to 4 (lowest) using each number only once. If your daughter would not do one of the activities, please write NO in that space. We cannot guarantee placement or placement in your first choice. These will be assigned on a first-come, first-served basis with preference for those Service Units who helped plan the event. Archery Rappelling Sling Shot Zipline Yes Yes No No My daughter has taken Knife Safety My daughter will be taking the bus to the camp. (This is only for those girls that will be attending / camping. This means they are not bringing anything larger than ONE trash bag full of supplies for the weekend) WHICH BUS LOCATION WILL YOU BE USING? James Bridger in Independence (291 and 78 Hwy) Walmart in Blue Springs (I-70 and Coronado) Sprouts Farmers Market (8383 N Booth Ave, Kansas City, MO 64158) GSKSMO HQ (8383 Blue Pkwy Dr, Kansas City, MO 64133)

4 GIRL HEALTH HISTORY Describe allergies, details of chronic conditions or health restrictions on additional sheet if needed. All information will be kept confidential. Name: Troop # Emergency Contact (Adult not at campout) Emergency Contact Phone Number: Secondary Phone: Family Physician: Phone: Immunizations are up to date and current? Yes No Please place an NA on the line if there is no information to report in the following areas: List any health conditions or recent serious injuries: (use back or another sheet if needed) List any allergies: Medications: Special dietary needs or restrictions

5 ADULT REGISTRATION & HEALTH HISTORY Adult Name: Troop # SU# Phone: Secondary Phone: Address: Troop Leader (If different): YOU MUST BE A REGISTERED GIRL SCOUT TO ATTEND. I am a registered Girl Scout. I have completed the Girl Scout Background Check. I am my troop s Camping 102 program trained adult. I am NOT my troop s Camping 102 program trained adult. My troop s Camping 102 program trained adult s name: I am my troop s CPR/First Aid/AED trained adult. I am NOT my troop s CPR/First Aid/AED trained adult. My troop s CPR/First Aid/AED trained adult s name:

6 ADULT HEALTH HISTORY Describe allergies, details of chronic conditions or health restrictions on additional sheet if needed. All information will be kept confidential. Name: Troop # Emergency Contact (Adult not at campout) Emergency Contact Phone Number: Secondary Phone: Family Physician: Phone: Immunizations are up to date and current? Yes No Please place an NA on the line if there is no information to report in the following areas: List any health conditions or recent serious injuries: (use back or another sheet if needed) List any allergies: Medications: Special dietary needs or restrictions

7 PERMISSION STATEMENT: REQUIRED FOR ALL PARTICIPANTS Participant Name: Troop # By signing I give the participant permission to participate in this overnight adventure. I understand that the participant will be exposed to risk of injury in camping conditions. I agree that to the best of my knowledge, the participant has the required skills and physical ability to participate. I also grant permission for the participant to be photographed and allow Zombie Committee to release said pictures for publicity purposes. I understand this activity may exposed participants to issues and discussions that are or could be considered sensitive or controversial in nature. I am comfortable with participation. The health history for the participant is correct as far as I know and the person here in described has my permission to engage in all activities, except as noted. I understand that every effort will be made to contact the emergency contact/parent, but in the event they cannot be reached, I give my permission to the program director to hospitalize and or secure proper treatment for the participant in an emergency. Signature of Adult participant or parent/guardian of participant Date PERMISSION STATEMENT: REQUIRED FOR ALL PARTICIPANTS Participant Name: Troop # By signing I give the participant permission to participate in this overnight adventure. I understand that the participant will be exposed to risk of injury in camping conditions. I agree that to the best of my knowledge, the participant has the required skills and physical ability to participate. I also grant permission for the participant to be photographed and allow Zombie Committee to release said pictures for publicity purposes. I understand this activity may exposed participants to issues and discussions that are or could be considered sensitive or controversial in nature. I am comfortable with participation. The health history for the participant is correct as far as I know and the person here in described has my permission to engage in all activities, except as noted. I understand that every effort will be made to contact the emergency contact/parent, but in the event they cannot be reached, I give my permission to the program director to hospitalize and or secure proper treatment for the participant in an emergency. Signature of Adult participant or parent/guardian of participant Date

8 TROOP SUMMARY PAGE Troop # Service Unit # Grade Level Troop Leader: Age Level: Junior Cadette Senior Ambassador Name Girls $25 / Person $10 Bus Fee T-Shirt $10.00 (Mark # Needed in Appropriate Size) YS YM AS AM AL AXL AXXL Archery Challenge Activity ($17) Zip-line Sling Shot Rappel Total Name Adults (no free adults) $25 / Person $10 Bus Fee YS T-Shirt $10.00 YM AS AM AL AXL AXXL Extra Adult Patch Camping 102 First Aid/CPR Total