Girl's Name_________________________________________________________

Address____________________________________________________________

City___________________________________________ Zip_________________

Phone(____)____________________

Age_______ Date of Birth_____/_____/_____ Grade in Fall__________

___ Registered Girl Scout Troop# _____ -or- ___ Non-Girl Scout (Fee: $10.00)

My choice of Session and Specialty: (Please complete one registration form for each session if attending more than one session. Copies of this form must be made for additional sessions.)

1st Choice Specialty___________________________________________________

Session #__________ Fee $_____________

2nd Choice Specialty___________________________________________________

Session #__________ Fee $_____________

___ I will be using the Bus Transportation*  Bus Stop___________________
      (* additional $84.00 per session; $38.00 for Session 2 only)

___I have applied for Financial Assistance.

___I have enclosed a deposit check for $25.00 (for each session)

___I would like the $25.00 camp deposit billed to my Credit Card:

      (Circle one) MasterCard       Visa       American Express       Discover       JCB

      Account_______________________________ Expiration Date____/____/____

      Cardholder's Signature_____________________________________________

Photographs of my daughter may be used in Girl Scout public relations: ____Yes ____No

I have read the Camp Chameleon information brochure and give my daughter permission to attend. I agree to cooperate with all regulations and procedures. I understand that the $25.00 deposit is not refundable after registration has been confirmed. I understand that if my daughter is not a registered Girl Scout, there is an additional $10.00 fee, which is applied toward her Girl Scout membership. As legal guardian of this child, I give permission for her to attend camp, for her to be transported out of camp for program and other purposes, and for emergency treatment to her in case of injury or illness to, from or during camp session.

Parent/Guardian Signature_____________________________ Date____/____/____

Name (Mother/Guardian)______________________________________________

Daytime Phone(____)____________________

Name (Father/Guardian)_______________________________________________

Daytime Phone(____)____________________