Community-Based Annual Permission Form

Please complete this permission form as completely as possible. Fields marked with an asterisk (*) are required. For assistance completing this form or if you have any questions, please email community@gsnorcal.org.

Please note that due to COVID-19, in-person activities are restricted by State, County, and other local guidelines. For current guidelines and information about your specific program, please reach out to the contact for your program. More information can be found on our GSNorCal webpage in the section called Coronavirus Updates: Working Together to Keep Our GSNorCal Community Healthy.

Contact Information

First Name of Girl Scout: *

Last Name of Girl Scout: *

Girl Email:

Girl Cell Phone:

Address:

City:

ZIP Code: *

County:

Date of Birth: * +

Grade in Fall 2021: *

School Attending: *

Emergency Contact Information

Parent/Guardian First Name: *

Parent/Guardian Last Name: *

Relationship to Child:

Primary Phone: *

Secondary Phone:

Email:

Emergency Contact Name:

Relationship to Child:

Phone:

Emergency Contact Name:

Relationship to Child:

Phone:

Demographic Data

The girl's ethnic background is (please check one):

Hispanic

Non-Hispanic

Permissions

The following permission require a yes or no answer, but not all programs will be participating in each of these activities. If you are unsure as to whether or not your Girl Scout will be participating in an activity, please reach out directly to your program instructor or email us at community@gsnorcal.org.

Permission for Virtual Meetings: My girl member has my permission to attend and participate in council-sponsored virtual meetings and activities through online platforms, like Zoom and Google Classroom. Guidelines outlined in GSNorCal's Safety Activity Checkpoint for Virtual Troop Meetings will be used to plan safe and meaningful meetings and activities. LINK for Safety Activity Checkpoint:

https://www.gsnorcal.org/content/dam/girlscouts-gsnorcal/documents/volunteer_resources/sac/virtual-troop-meetings.pdf

Some programs are virtual, some are in-person. Please confirm with your program instructors. *

Yes

Permission for Trips: My girl member has permission to travel to, attend and participate in troop and council-sponsored activities that are 1) located within one hour’s driving time of regular meeting place, 2) not exceeding 6 hours, and 3) not considered high risk activities as outlined in the Volunteer Essentials, which can be found here: http://ve.gsnorcal.org/ *

Yes

Permission to Participate in Product Program: My girl member has permission to participate in the Fall Take Action and Cookie Product Programs. I agree to accept financial responsibility for all products and money she receives and understand that Girl Scouts reserves the right to take appropriate action to secure payment for product received by me. I further understand that she must have adult guidance at all times when participants in a Girl Scout product sale program and that my girl member may not take product orders before the official start of the product program dates as determined by Girl Scouts of Northern California. *

Yes

Permission to Use Photographs: I hereby consent that the videotapes, photographs, motion pictures, electronic images and/or audio recordings of my girl member may be used by Girl Scouts for Public Relations and Publicity purposes. I understand that her last name and residence will not be used for publicity purposes. *

Yes

Permission for Emergency Medical Treatment: In the event of an emergency, every effort will be made to contact a parent/guardian or emergency contact. If no contact can be made, I hereby give authorization to Girl Scouts of Northern California to seek treatment for the Girl Scout by a licensed physician pursuant to California Family Code Section 6910 and California Civil Code Section 25.8. I know of no reason(s) why she may not participate in prescribed activities except as noted on the Health History Form. If permission for emergency medical treatment is not given, please prepare a signed statement providing the reason, a release of liability, and alternate instructions and attach to this form. *

Yes

Please upload signed statement: *

Permission to Survey: My initials certify that I understand that my girl member may occasionally be asked to participate in evaluations/surveys as part of her Girl Scout activities. I understand that her participation is voluntary, and that she will neither receive compensation of any form for participating nor will her standing in her Girl Scout sponsored programs be affected, if she chooses not to participate. I further understand that my girl member’s confidentiality will be protected throughout the entire project, and that she will never be identified in any publication, written or spoken. I understand that she may discontinue taking evaluations/surveys at any time without consequence. *

Yes

Special Accommodations and Allergies: My daughter/ward requires the following special accommodations and has the following allergies (write "none" if there are none): *

Electronic Signature

Parent Agreement: I have read and understand this Annual Parent Permission Form. I may change or revoke any aspect of this agreement at any time by submitting my request, in writing to the troop/group leader. Please type your full name here: *

Electronic Signature: By typing my name on this form, I am entering my "electronic signature" (as defined in The California Uniform Electronic Transactions Act 1633.1 - 1633.17) and certifying that I have read, fully understand and accept all terms of this agreement.
Please type your full name here: *

Enter the word in the image *
captcha

Published June 11th, 2021

* Please Note: Once you submit this form, you'll have the option to print the form contents on the following page.

Girl Scouting builds girls of courage, confidence and character that make the world a better place. 2014 Girl Scouts of Northern California