Trip Request Form

This information will be sent to the Service Unit Manager. Please complete all necessary information then press Submit.

Part A All trips
Troop #: Grade: Date(s) of trip:

Trained Troop Leader attending (See Guidelines on back for required training):
Phone: Cell Phone: Email:
List the types of activities in which the girls will participate:
Name and address of destination: Phone:

Departure from: Time:

Return to: Time:

# Girls in troop: # Girls attending # Adults attending

Total cost of trip per girl:    Girl     Family Troop

Total cost of trip per adult: Adult Troop

Troop Emergency Contact: Phone:
Do you have Parent/Guardian Trip/Event Permission slips and Girl Health Record forms?
Yes In Progress
(Note: Health Records must be on site for all participants (girl and adult); permission slips must be on site for all girls.)
Name of First Aider/CPR:
Check Safety-Wise for level required.
Level I Level II    First Aid expires: CPR expires:
If required, additional Girl Scout Insurance has been or will be secured. YES NO

Mode of transportation: Private car Train Approved bus (see website for list) Other

I have read and am willing to meet the standards in Safety-Wise and agree to follow all rules and regulations of Girl Scouts of Connecticut.
Name of Troop Leader for electonic signature: Date: 7/29/2010 Email:

Address: Phone: Cell:

City:         State: Zip:

Part B 1 or 2 nights
Past travel / camping experience:
What type of accommodations will be used? (If more than one girl per bed, sleeping bags are required.)

Name(s) of T-2-certified personnel:
(Needed if on a basic field trip away from a troop ofs regular meeting location)
Name(s) of T-3-certified personnel:
(Needed when troop is using a fire, cooking, or for an overnight whether in a heated or unheated space)

For a list of training level descriptions, please refer to the website under CurrentPaths of Training for Legacy Councils and Girl Scouts of Connecticut.

Part C Activities which require certified personnel and/or 3 or more nights (check Safety-Wise)
Lifeguard or other appropriate certified personnel: Position:

Name: Certification expires (if relevant):
Physician examination forms for all attendees (both girl and adult) have been completed. YES NO In Progress (See Safety-Wise)
Supplemental insurance has been purchased. YES NO In Progress (Required for trips of 3 or more nights)

Name and phone numbers of all going on this trip:
This is needed for all trips.

Last updated 6/23/2010