Troop and SU Activity Approval Form

Troop and SU Activity Approval Form
What type of activity?*

Day TripOvernight Activity (Note: Girl Scouting has a travel progression for where and how long travel is allowed for the different levels. Please review the Safety Activity Checkpoint on Travel prior to making arrangements.)
How many Girl Scout members from each grade level will be attending? Please use the levels at the time of the activity.
How many current Girl Scout volunteers will be attending? For all activities, there must be at least 2 unrelated volunteers, one of whom is female. More volunteers may be needed, depending on specific activity and girls' grade levels. (Review current Safety Activity Checkpoints for safety ratio.)
How many other adult Girl Scout members will be attending?
How many Non-Girl Scout Participants will be attending?
What is the grade level of the youngest Girl Scout participating?*

DaisyBrownieJuniorCadetteSeniorAmbassador
Select the activities that best fit what you will be doing: (Daisies)*

Amusement ParkBackpackingBicyclingCampingClimbing and Adventure/Challenge CoursesClimbing and Adventure/Climbing and RappellingCommunity Clean-UpDownhill Skiing and SnowboardingEventFencingFishing and Ice FishingHayridesHorseback RidingIce SkatingIn-Line Skating and Roller SkatingInflatables/Bounce Houses (UPDATE: Trampoline Parks are not permitted for Daisies under 6 years of age)Offshore Water/Large Passenger VesselsPaddle Sports/CanoeingPaddle Sports/Row BoatingSledding, Tobogganing, and Snow TubingSwimmingTarget Sports/Sling ShotTools-Hand and PowerTravel/Trips (Overnight travel is permitted for one night; two if accompanied by parent)
Select the activities that best fit what you will be doing: (Brownies)*

Amusement ParkBackpackingBicyclingCampingClimbing and Adventure/Challenge CoursesClimbing and Adventure/Climbing and RappellingClimbing and Adventure/Zip LiningCommunity Clean-UpCross-Country SkiingDownhill Skiing and SnowboardingEventFencingFishing and Ice FishingHayridesHorseback RidingIce SkatingIndoor TrampolineIn-Line Skating and Roller SkatingInflatables/Aquatic Bounce Houses and SlidesInflatables/Bounce HousesInflatables/Log RollingOffshore Water/Large Passenger VesselsPaddle Sports/CanoeingPaddle Sports/Corcl BoatsPaddle Sports/KayakingPaddle Sports/Row BoatingPaddle Sports/White Water RaftingPocket Knife/Jackknife SafetySailingSledding, Tobogganing, and Snow TubingSwimmingTarget Sports/Air/BB GunsTarget Sports/ArcheryTarget Sports/Sling ShotTarget Sports/Target PaintballTools-Hand and PowerTravel/Trips (Overnight travel is permitted for 2 nights; limited exceptions of longer timeframes in the Southeastern USA are permitted with a parent)
Select the activities that best fit what you will be doing: (Juniors)*

Amusement ParkBackpackingBicyclingCampingClimbing and Adventure/Challenge CoursesClimbing and Adventure/Climbing and RappellingClimbing Adventure/Recreational Tree ClimbingClimbing and Adventure/Zip LiningCommunity Clean-UpCross-Country SkiingDownhill Skiing and SnowboardingEventFencingFishing and Ice FishingGo-KartsHayridesHorseback RidingIce SkatingIndoor SkydivingIndoor TrampolineIn-Line Skating and Roller SkatingInflatables/Aquatic Bounce Houses and SlidesInflatables/Aquatic Climbing WallsInflatables/Bounce HousesInflatables/Bubble SoccerInflatables/Log RollingOffshore Water/Large Passenger VesselsPaddle Sports/CanoeingPaddle Sports/Corcl BoatsPaddle Sports/KayakingPaddle Sports/Row BoatingPaddle Sports/Standup Paddle BoardingPaddle Sports/White Water RaftingPocket Knife/Jackknife SafetyRocketry/Model RocketrySailingSledding, Tobogganing, and Snow TubingSnorkelingSpelunking/CavingSurfingSwimmingTarget Sports/3-D ArcheryTarget Sports/Air/BB GunsTarget Sports/ArcheryTarget Sports/Sling ShotTarget Sports/Target PaintballTethered Balloon RidesTools-Hand and PowerTravel/Trips (Overnight trips within the Southeastern US)TubingWaterskiing and WakeboardingWindsurfing/Sail Boarding
Select the activities that best fit what you will be doing: (Cadettes)*

Aerial FitnessAmusement ParkBackpackingBicyclingCampingClimbing and Adventure/Challenge CoursesClimbing and Adventure/Climbing and RappellingClimbing Adventure/Recreational Tree ClimbingClimbing and Adventure/Zip LiningCommunity Clean-UpCross-Country SkiingDownhill Skiing and SnowboardingEventFencingFishing and Ice FishingGo-KartsHayridesHorseback RidingIce SkatingIndoor SkydivingIndoor TrampolineIn-Line Skating and Roller SkatingInflatables/Aquatic Bounce Houses and SlidesInflatables/Aquatic Climbing WallsInflatables/Bounce HousesInflatables/Bubble SoccerInflatables/Log RollingOffshore Water/Large Passenger VesselsPaddle Sports/CanoeingPaddle Sports/Corcl BoatsPaddle Sports/KayakingPaddle Sports/Row BoatingPaddle Sports/Standup Paddle BoardingPaddle Sports/Whitewater RaftingPocket Knife/Jackknife SafetyRocketry/Model RocketrySailingScuba DivingSegwaySledding, Tobogganing, and Snow TubingSnorkelingSpelunking/CavingSurfingSwimmingTarget Sports/3-D ArcheryTarget Sports/Air/BB GunsTarget Sports/ArcheryTarget Sports/Knife ThrowingTarget Sports/Muzzle LoadingTarget Sports/RifleTarget Sports/Shotgun-Trap/Skeet ShootingTarget Sports/Sling ShotTarget Sports/Target PaintballTarget Sports/Tomahawk/Hatchet ThrowingTethered Balloon RidesTools-Hand and PowerTravel/TripsTubingWaterskiing and WakeboardingWindsurfing/Sail Boarding
Select the activities that best fit what you will be doing: (Seniors)*

Aerial FitnessAmusement ParkBackpackingBicyclingCampingClimbing and Adventure/Challenge CoursesClimbing and Adventure/Climbing and RappellingClimbing Adventure/Recreational Tree ClimbingClimbing and Adventure/Zip LiningCommunity Clean-UpCross-Country SkiingDownhill Skiing and SnowboardingEventFencingFishing and Ice FishingGo-KartsHayridesHorseback RidingIce SkatingIndoor SkydivingIndoor TrampolineIn-Line Skating and Roller SkatingInflatables/Aquatic Bounce Houses and SlidesInflatables/Aquatic Climbing WallsInflatables/Bounce HousesInflatables/Bubble SoccerInflatables/Log RollingOffshore Water/Large Passenger VesselsPaddle Sports/CanoeingPaddle Sports/Corcl BoatsPaddle Sports/KayakingPaddle Sports/Row BoatingPaddle Sports/Standup Paddle BoardingPaddle Sports/Whitewater RaftingPocket Knife/Jackknife SafetyRocketry/Model RocketrySailingScuba DivingSegwaySledding, Tobogganing, and Snow TubingSnorkelingSnowshoeingSpelunking/CavingSurfingSwimmingTarget Sports/3-D ArcheryTarget Sports/Air/BB GunsTarget Sports/ArcheryTarget Sports/Knife ThrowingTarget Sports/Muzzle LoadingTarget Sports/PistolTarget Sports/RifleTarget Sports/Shotgun-Trap/Skeet ShootingTarget Sports/Sling ShotTarget Sports/Target PaintballTarget Sports/Tomahawk/Hatchet ThrowingTethered Balloon RidesTools-Hand and PowerTravel/TripsTubingWaterskiing and WakeboardingWindsurfing/Sail Boarding
Select the activities that best fit what you will be doing: (Ambassadors)*

Aerial FitnessAmusement ParkBackpackingBicyclingCampingClimbing and Adventure/Challenge CoursesClimbing and Adventure/Climbing and RappellingClimbing Adventure/Recreational Tree ClimbingClimbing and Adventure/Zip LiningCommunity Clean-UpCross-Country SkiingDownhill Skiing and SnowboardingEventFencingFishing and Ice FishingGo-KartsHayridesHorseback RidingIce SkatingIndoor SkydivingIndoor TrampolineIn-Line Skating and Roller SkatingInflatables/Aquatic Bounce Houses and SlidesInflatables/Aquatic Climbing WallsInflatables/Bounce HousesInflatables/Bubble SoccerInflatables/Log RollingOffshore Water/Large Passenger VesselsPaddle Sports/CanoeingPaddle Sports/Corcl BoatsPaddle Sports/KayakingPaddle Sports/Row BoatingPaddle Sports/Standup Paddle BoardingPaddle Sports/Whitewater RaftingPocket Knife/Jackknife SafetyRocketry/Model RocketrySailingScuba DivingSegwaySledding, Tobogganing, and Snow TubingSnorkelingSpelunking/CavingSurfingSwimmingTarget Sports/3-D ArcheryTarget Sports/Air/BB GunsTarget Sports/ArcheryTarget Sports/Knife ThrowingTarget Sports/Muzzle LoadingTarget Sports/PistolTarget Sports/RifleTarget Sports/Shotgun-Trap/Skeet ShootingTarget Sports/Sling ShotTarget Sports/Target PaintballTarget Sports/Tomahawk/Hatchet ThrowingTethered Balloon RidesTools-Hand and PowerTravel/TripsTubingWaterskiing and WakeboardingWindsurfing/Sail Boarding
Include additional comments if needed.
Backpacking:

Backpacking is not recommended for Daisies and Brownies, due to weight restrictions on their small frames, and the need when backpacking to be able to carry all their supplies needed to camp.
Camping

Ensure that at least one adult has attended Outdoor Education training as required by your council. In addition, follow the adult-to-girl ratios.
Climbing and Adventure/Challenge Courses

Instructor trained and certified by a verified agency who demonstrates competence in equipment maintenace, safety and rescue techniques, proper use of the course, and hands-on training. In addition, follow the adult-to-girl ratios.

*Daisies and Brownies may participate only in activities that have been designed for their grade levels and that have equipment that suit the size and ability of each girl. Outdoor high ropes, and high elements are only permitted for Juniors and older.
Climbing and Adventure/Climbing and Rappelling

*Daisies and Brownies are limited in what is permitted, please check the master chart on the safety activity checkpoint. Daisies and Brownies can do slacklining and low challenge elements. Outdoor high ropes, high elements, and rappelling are only permitted for Juniors and older. *Brownies can participate in most indoor climbing activities. A minimum of one facilitator and an additional adult are present, and facilitators are skilled in selecting appropriate activities, teaching and supervising spotting and lowering techniques, and modifying tasks to meet girls' needs. In addition, follow the adult-to-girl ratios.
Climbing and Adventure/Recreational Tree Climbing

A certified instructor with documented experience in leading and teaching tree climbing is required. In addition, follow the adult-to-girl ratios. In recreational tree climbing, girls use ropes, harnesses, saddled, and climbing techniques to ascend into the crowns of trees.
Climbing and Adventure/Zip Lining

Not permitted for Daisies, except for playground zip lines. *Canopy tours are not permitted for Daisies or Brownies.
Computer and Internet Use

All girls, as well as their parents/guardians, must read, agree to, and abide by the Girl Scout Internet Safety Pledge when going online. Page 77 of 2021 SAC.
Cross-Country Skiing

First-aider has a current certificate in first-aide, including adult and child CPR or CPR/AED, and is prepared to handle cases of frostbite, cold exposure, hypothermia, sprains, fractures, and altitude sickness.
Downhill Skiing and Snowboarding

Instructors are certified by the Professional Ski Instructors of America (PSIA) and the American Association of Snowboard Instructors (AASI) or possess equivalent certification.
Fencing

One adult is a certified fencing instructor or has equivalent certification or documented experience according to your council's guidelines. Ensure that there is a ratio of one instructor for every ten girls. Additional adults must be present to meet the adult-to-girl ratios.
Fishing and Ice Fishing

Adult or fishing instructor holds American Red Cross Basic Water Rescue certification or posses equivalent certification or documentation experience (competencies); the ratio of instructor to participant is one to ten. Additional adults must be present to meet the adult-to-girl ratios. You must submit the Ice Safety Quiz found on page 95 of the 2021 SAC to council.
Geocaching

*Daisies are permitted when working with older girls and adults as part of another outdoor activity.
Go-Karts

Junior can't operate self-driving go-karts, and must participate in activities on a rail system.
Hayrides

Qualified driver who is licensed to drive a vehicle in the jurisdiction, is at least 21 years of age, and has experience hauling a trailer and driving the vehicle being used. Additional adults must be present to meet the adult-to-girl ratios.
Horesback Riding

Riding instructors are adults (at least 18 years old) who have current certification from an accredited horsemanship instructor training organization, such as the Certified Horsemanship Association and American Association for Horsemanship Safety, or documented proof of a minimum of three years' experience successfully instructing in a general horseback riding program. Additional adults must be present to meet the adult-to-girl ratios.
Indoor Skydiving

Instructor holds instructional certification from the International Bodyflight Association or has council approved equivalent certification or documented experience and skill in teaching and/or supervising indoor skydiving.
Inflatables/Bounce Houses

*Daisies can only participate in bounce houses that are specific for their age, height and/or weight.
Inflatables/Aquatic Climbing Walls

Aquatic Climbing Walls are not permitted for Daisies and Brownies. Juniors and above may participate in aquatic climbing walls as long as they are strong swimmers and can swim in water deeper than five feet.
Land Sports

Ensure that adults are well versed in rules and aware of safety concerns for the designated sport
Laser Tag

Verify vendor is licensed and carries insurance.
Offshore Water/Larger Passenger Vessels

Vessels (ferries, cruise ships, whale-watching watercraft and airboats) must be licensed by the US Coast Guard. Follow the adult-to-girl ratios.
Paddle Sports/Canoeing

Follow Master Paddling Chart for certification by water type. At least one adult instructor or guide is currently certified by the American Canoe Association, the American Red Cross, or other sponsoring organization approved by your council. Certifications must be appropriate for the activity. In addition, follow the adult-to-girl ratios.
*Not recommended for Daisies except with an experienced adult in each canoe on flat water."
Paddle Sports/Corcl Boats

Lifeguards have current certification in American Red Cross (ARC) Lifeguarding with Waterfront Module or equivalent and have the proper training, experience, and rescue equipment for the body of water being used. In addition, follow the adult-to-girl ratios.
Paddle Sports/Kayaking

Follow Master Paddling Chart for certification by water type. At least one adult instructor or guide is currently certified by the American Canoe Association, the American Red Cross, or other sponsoring organization approved by your council. Certification must be appropriate for the activity. In addition, follow the adult-to-girl ratios.
Paddle Sports/Row Boating

*Daisies must use basic row boats only if they have an adult in the boat with them. In addition, follow the adult-to-girl ratios.
Paddle Sports/Standup Paddle Boarding

Lifeguards have current certification in American Red Cross (ARC) Lifeguarding with Waterfront Module or equivalent and have the proper training, experience, and rescue equipment for the body of water being used. In addition, follow the adult-to-girl ratio
Paddle Sports/Whitewater Rafting

Follow Master Paddling Chart for certification by water type. *Brownies (Class I-II rapids only). No Girl Scout is permitted on Class V or VI rapids. Guides have American Canoe Association (ACA) Rafting Level 4 instructor or higher certification, and/or International Rafting Federation (IRF) Guide certification. In addition, follow the adult-to-girl ratios.
Pocket Knife and Jackknife Safety

Must have Girl Scouts sign the Pocket Knife/Jackknife Safety Pledge. Page 159 of 2021 SAC.

*Not Permitted for Daisies. Daisies can learn basic knife safety with cardboard/wood examples.
Sailing

Ensure that the adult or sailing instructor is certified as a sailing instructor or sailing counselor by US Sailing, holds American Red Cross Small Craft Safety Certification, or possesses equivalent certification or documented experience according to your council's guidelines.
Scuba Diving

Scuba diving teacher holds instructional certification from Scuba Schools International (SSI), PADI, the National Association of Underwater Instructors (NAUI), or the YMCA. The instructor-to-girl ratio is one to four. In addition, follow the adult-to-girl ratios.
Segway

Vendor must be licensed and carry insurance. Segways are only allowed to be used in a pedestrian environment, not on public roads.
Skateboarding

Skate parks should only be used by non-beginner skaters. Follow appropriate adult-to-girl ratios
Sledding, Tobogganing, and Snow Tubing

Follow appropriate adult-to-girl ratios. Girls must go feet-first and helmets are strongly recommended. Girls are not permitted to be towed behind any vehicle, including snowmobiles.
Snorkeling

Snorkeling instructor holds instructional certification from Scuba Schools International (SSI) or the Professional Association of Diving Instructors (PADI), or has equivalent certification. If the scuba instructor is not also a certified lifeguard, you will need a lifeguard present. Lifeguards need current ARC Lifeguarding plus Waterfront Module, or YMCA Waterfront Lifeguarding certification or equivalent. One lifeguard is needed for every 25 girls. In addition, follow the adult-to-girl ratios listed in the Swimming SAC.
Snowshoeing

Instruction is given by an adult with experience teaching and/or supervising snowshoeing or has documented experience.
Spelunking/Caving

A guide with documented experience in cave exploration accompanies the group into cave.
Surfing

Instructors should hold a certification from the National Surf Schools and Instructors Association, the International Surfing Association, or similar certification. Ocean lifeguard certifications are required. The instructor-to-girl ratio is one to four. In addition, follow the adult-to-girl ratios.
Swimming

Follow the lifeguard certification requirements and ratios listed in the Swimming SAC.
Target Sports/3-D Archery

One adult is certified by the National Field Archery Association, USA Archery, or Easton Foundation. In addition, one adult to every ten Juniors, Cadettes, Seniors, and Ambassadors is required.
Target Sports/Air/BB Guns

One adult is a certified National Rifle Association range safety officer or USA Shooting Sports instructor. In addition, one adult to every five Brownies and one adult to every ten Juniors, Cadettes, Seniors, and Ambassadors is required.
Target Sports/Archery

One adult has certification from the National Field Archery Association, USA Archery, or Easton Foundation. In addition, one adult to every five Brownies and one adult to every ten Juniors, Cadettes, Seniors, and Ambassadors is required.
Target Sports/Knife Throwing

One adult instructor trained in knife throwing safety, form and technique, range rules, and emergency procedures. In addition, one adult to every two Cadettes, Seniors, and Ambassadors is required.
Target Sports/Muzzle Loading

*Girls must be 12 years or older to participate. One adult is a certified National Rifle Association range safety officer or USA Shooting Sports instructor. In addition, one adult to every two Cadettes, Seniors, and Ambassadors in required.
Target Sports/Pistol

Girls must be 14 years or older to participate. One adult is a certified National Rifle Association range safety officer or USA Shooting Sports instructor. In addition, one adult to every four Cadettes, Seniors, and Ambassadors is required.
Target Sports/Rifle

*Girls must be 12 years or older to participate. One adult is a certified National Rifle Association range safety officer or USA Shooting Sports instructor. In addition, one adult to every eight Cadettes, Seniors, and Ambassadors in required.
Target Sports/Shotgun-Trap/Skeet Shooting

*Girls must be 12 years or older to participate. One adult is a certified National Rifle Association range safety officer or USA Shooting Sports instructor. In addition, one adult to every eight Cadettes, Seniors, and Ambassadors in required.
Target Sports/Sling Shot

One adult instructor trained in slingshot safety, form and technique, range rules, and emergency procedures. In addition, one adult to every five Daisies and Brownies, and one adult to every ten Juniors, Cadettes, Seniors and Ambassadors is required.
Target Sports/Target Paintball

One adult is trained in paintball safety, range rules, and emergency procedures. In addition, one adult to every five Brownies and one adult to every ten Juniors, Cadettes, Seniors, and Ambassadors is required.
Target Sports/Tomahawk/Hatchet Throwing

One adult instructor trained in hatchet/ax throwing safety, form and technique, range rules, and emergency procedures. In addition, one adult to every two Cadettes, Seniors, and Ambassadors is required.
Tethered Balloon Rides

Ensure operators have liability insurance and are licensed through the Federal Aviation Administration. Pilots must be currently licensed. In addition, follow adult-to-girl ratios.
Tools-Hand and Power

See the specific activity for grade level permissions and progression. Certain power tools are not permitted which apply to all grade levels. Page 207 of 2021 SAC.
Travel/Trips

See SAC for grade-level trip and travel length recommendations. Follow adult-to-girl ratios.
Tubing

One adult must be certified in American Red Cross Small Craft Safety and the Moving Water module from the American Red Cross, and have experience teaching and/or supervising tubing activities. If tubing behind a motorboat, make sure the driver is an adult and has a valid license to operate the motorboat. Girls are not permitted to be towed by jet skis or wave runners. Follow the lifeguard certification requirements and ratios listed in the Swimming SAC.
Waterskiing and Wakeboarding

Endure that the adult or instructor is certified by USA Water Ski or possess equivalent certification or documented experience according to your council's guidelines. Confirm that the boat driver is an adult is an adult, has an appropriate license, and is skilled in operating the watercraft. Follow the lifeguard certification requirements and ratios listed in the Swimming SAC.
Windsurfing/Sail Boarding

In addition to lifeguard, at least one adult present should have small craft safety certification or equivalent experience. Follow the lifeguard certification requirements and ratios listed in the Swimming SAC.
What is the farthest distance the group will be traveling?*

Local Point of Interest (like a National/State Park in our council)Nearby CityGirl Scout CampWithin 4 Hours of Home
What is the farthest distance the group will be traveling?*

Local Point of Interest (like a National/State Park in our council)Nearby CityGirl Scout CampSoutheastern USNational Travel (Cadette and older only)International Travel
Troop and Trip Information
Troop Number*
Service Unit
Your Name*

First NameLast Name
Your Phone Number*

Area CodePhone Number
Your Alternate Phone Number

Area CodePhone Number
Your Email*
example@example.com
Your Volunteer Position
Adult-in-Charge on Trip (if someone other than you)

First NameLast Name
Adult-in-Charge Phone Number

Area CodePhone Number
Adult-in-Charge Alternate Phone Number

Area CodePhone Number
Adult-in-Charge Email
example@example.com
Emergency Contact Name (not attending activity)*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Alternate Phone Number

Area CodePhone Number
Emergency Contact Email*
example@example.com
Activity Start Date*

MonthDayYear
Date
Activity End Date*

MonthDayYear
Date
Name(s) and Address(es) of Destination(s)*
Mode(s) of Transportation (select all that apply)*

Private VehicleTrainRental/Charter Bus (For charter buses, Council must review and sign agreement.PlaneOther
For overnight travel, please list the names of any drivers who are transporting non-family member girls. GSCSA will conduct a driver license's/motor vehicle check on those drivers prior to trip departure. A link from our vendor Asurint will be sent to those volunteers to complete.*

Activity Checklist (Click "Yes" or "No" for the following statements):*

	Yes	No
*All girls and adult volunteers are registered members of Girl Scouts of Southern Appalachians.
*I understand that additional activity insurance may be required for these activities and that I must select the appropriate insurance type and submit your payment to the council office after completing this form.
*I understand that if this activity will result in earning money for the troop or service unit, I may also be required to submit an application for money earning and will take steps to do so.
*All standards and guidelines as stated in Volunteer Essentials and Safety Activity Checkpoints will be adhered to.
*Parental Permission Activity Forms must be received from all girl participants and Health History and Emergency Medical Authorization forms must be received from all participants.
*Appropriate girl/volunteer ratios will be met.
*GSCSA Emergency Procedures will be followed.
*All participating adults will have the phone numbers of the Council Office (800-474-1912) and in case of emergency call 911.

Adult Training/Certificate Checklist*

*Depending on the type of activity, certification/training may not be applicable.
First Aid/CPR*
Other Training/Certification Held (if needed for activity)
Other Training/Certification Held (if needed for activity)
Trip Participants and Insurance
If the answer is "yes" to any of the following questions, you will need to select an additional insurance plan.
My activity is 3 nights or more. *
My activity is high-risk.*
My activity includes non-member participants.*
My activity is international.*
Please indicate the insurance plan being requested:

Plan 2-Troop activity lasting more than two nights (three nights when one of the nights is an official federal holiday) and/or troop activity or service unit event with non-registered participants. - $.11 per day per participant. (Accident only coverage.)Plan 3E-Troop or service unit activity excluded under the basic plan, coverage for accident and sickness. - $.29 per day per registered and non-registered participant. (Coordinates with any family health plan.)Plan 3P-Troop or service unit activity excluded under the basic plan, coverage for accident and sickness. Required for trips of more then two nights. - $.70 per day per registered and non-registered participants. (Primary Coverage Plan)
Please indicate the insurance plan being requested:

Plan 3PI-Troop or service unit international activity with coverage for accident and sickness. $1.17 per day per registered and non-registered participants. (Primary coverage, not subject to coordination of benefits.) (includes emergency travel assistance. Strongly recommended by Mutual of Omaha.)
*The minimum cost for all premiums is $5.00. Additional activity insurance can not be purchased for anyone under age 5. A staff member will contact you about the insurance premium total.
Would you like staff to contact you regarding additional insurance? Please note: additional insurance is required for international travel.
Volunteer Agreement

I, and all adult volunteers participating in this trip/activity, have reviewed all of the policies, procedures, and guidelines of the Girl Scouts of the Southern Appalachians and GSUSA as stated in Volunteer Essentials and the Safety Activity Checkpoints and agree to follow them.

I understand that a minimum of 10 business days is required for submission of this form.

I understand that no insurance payments will be accepted by the council on Friday's afternoon for activities taking place that Saturday or Sunday.
By initialing here, you are stating that you have reviewed and understand GSCSA's COVID-19 guidance and are agreeing to follow it:
Type your initials
By initialing here, you are saying that you have reviewed the GSCSA COVID-19 waiver and will have all in-person participants sign and keep these on file with your troop health documents:
Type your initials
Signature*

Clear
Date Form Submitted
Should be Empty: