Program/Event Name

Month/Day/Year

/ /

Start Time

2nd Choice Program

Month/Day/Year

/ /

Time

Troop Leader/Parent Name

Troop #

Street Address

City, State, ZIP

Phone: Day

Phone: Other

e-Mail Address

   Number of Girls

   x Registration Fee

   + Number of Adults

   x Registration Fee

(Total # of Participants)

+ Membership Fee ($10 per participant if not already registered as a Girl Scout)

   = Total Amount Paid

Age Level

Select One Daisy Brownie Junior Cadette Senior

Payment Type

Select One Visa MasterCard Discover

Credit Card Number*

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Credit Card VIN Number

Expiration Date

Select Month January February March April May June July August September October November December    Select Year 2007 2008 2009 2010 2011 2012 2013 2014

Name As It Appears On Card