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J:\FORMS\01Troop Management Forms\Field Trips Made Easy - 08.doc 7/8/2008 RC Frm: ww 2007 1 Girl Scouts of Southwest Texas 5 Steps to... FIELD TRIPS MADE EASY! You will also need the following forms (available in the Resource Center or at www.sagirlscouts.org 1.) Insurance Claim Forms (2 per Driver’s Folder) 2. Insurance Brochure (2 per Driver’s Folder) 3. Procedures for Serious Accidents, Emergencies, or Fatalities cards (2 per Driver’s Folder) So... you're planning to take your girls on a field trip...great idea! Your girls will love it! For girls, a field trip means fun, excitement and adventure. For some leaders, however, a field trip could mean confusion, hysteria and mass chaos. But of course, you're not one of those leaders because you have everything under control and have planned ahead! You're planning to prepare several "Driver's Folders" so everything will go smoothly and you can have as much fun as the girls do. To complete your Driver's Folders you will need the parents to provide important information on their daughters. A perfect time to do this is at the first parent meeting, but if not, it can be done at any time during the year. Preparing the folders takes a little bit of time and effort from both the leader and the parent, but it is time well spent. Once the folders are complete, you will always be ready for a field trip. The attached packet contains a copy of all the forms needed for your Driver's Folder. I hope it will be helpful to you and that you will have many safe, enjoyable, and well prepared field trips! 5 Steps to Prepare Your Drivers Folders STEP 1: the leader will complete; 1. the Field Trip Roster with the name of each girl in the troop (pg. 7), 2. the names and numbers requested on the Procedures for Serious Accident, Emergencies, or Fatalities Form (pg. 9). STEP 2: the parents will complete; 1. a Health History Form on their daughter (pg. 11), 2. one section of the Troop Roster and Emergency Information - it MUST be legible! (pg. 13-22) STEP 3: after the above information has been completed, you are ready to make copies of each for your folders. The size of your troop will determine the number of copies and folders you will need. (Probably about one folder for every four girls.) If you have decided to make five folders, you will need to make five copies of each of the forms listed below. Be sure to copy EACH GIRL'S HEALTH HISTORY RECORD five times. There will be a record on every girl in each folder. This will eliminate the "shuffling" of papers on the day of the trip and prevent important documents from being lost. Sort and arrange your copies so that each "Driver's Folder" contains the following materials in this order: 1. one copy of the driver information sheet titled How to Use this...”Driver’s Folder” (pg. 5) 2. one copy of the completed Field Trip Roster (pg. 7) 3. one copy of the Procedures for Serious Accidents, Emergencies, and Fatalities Form (pg. 9) 4. one copy of the completed Trop Roster and Emergency Contact Information Form (pg.13) 5. one copy of each girl's & adult’s completed Health History Form (pg. 11) STEP 4: in the pocket of each folder add at least one Insurance Brochure and Insurance Claim Form. STEP 5: label one of the folders "Emergency Contact Person" and all the others "Driver’s Folder". **Your folders are now complete! Plan and prepare for your trip using the guidelines that follow and ..... ENJOY THE FIELD TRIP!!!

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Page 1: 5 Steps to FIELD TRIPS MADE EASY!J:\FORMS\01Troop Management Forms\Field Trips Made Easy - 08.doc 7/8/2008 RC Frm: ww 2007 1 Girl Scouts of Southwest Texas 5 Steps to... FIELD TRIPS

J:\FORMS\01Troop Management Forms\Field Trips Made Easy - 08.doc 7/8/2008 RC Frm: ww 2007 1

Girl Scouts of Southwest Texas

5 Steps to... FIELD TRIPS MADE EASY!

You will also need the following forms (available in the Resource Center or at www.sagirlscouts.org 1.) Insurance Claim Forms (2 per Driver’s Folder) 2. Insurance Brochure (2 per Driver’s Folder) 3. Procedures for Serious Accidents, Emergencies, or Fatalities cards (2 per Driver’s Folder)

So... you're planning to take your girls on a field trip...great idea! Your girls will love it! For girls, a

field trip means fun, excitement and adventure. For some leaders, however, a field trip could mean confusion, hysteria and mass chaos. But of course, you're not one of those leaders because you have everything under control and have planned ahead! You're planning to prepare several "Driver's Folders" so everything will go smoothly and you can have as much fun as the girls do. To complete your Driver's Folders you will need the parents to provide important information on their daughters. A perfect time to do this is at the first parent meeting, but if not, it can be done at any time during the year. Preparing the folders takes a little bit of time and effort from both the leader and the parent, but it is time well spent. Once the folders are complete, you will always be ready for a field trip. The attached packet contains a copy of all the forms needed for your Driver's Folder. I hope it will be helpful to you and that you will have many safe, enjoyable, and well prepared field trips!

5 Steps to Prepare Your Drivers Folders

STEP 1: the leader will complete; 1. the Field Trip Roster with the name of each girl in the troop (pg. 7), 2. the names and numbers requested on the Procedures for Serious Accident, Emergencies, or Fatalities Form (pg. 9).

STEP 2: the parents will complete; 1. a Health History Form on their daughter (pg. 11), 2. one section of the Troop Roster and Emergency Information - it MUST be legible! (pg. 13-22)

STEP 3: after the above information has been completed, you are ready to make copies of each for your folders. The size of your troop will determine the number of copies and folders you will need. (Probably about one folder for every four girls.) If you have decided to make five folders, you will need to make five copies of each of the forms listed below. Be sure to copy EACH GIRL'S HEALTH HISTORY RECORD five times. There will be a record on every girl in each folder. This will eliminate the "shuffling" of papers on the day of the trip and prevent important documents from being lost.

Sort and arrange your copies so that each "Driver's Folder" contains the following materials in this order: 1. one copy of the driver information sheet titled How to Use this...”Driver’s Folder” (pg. 5) 2. one copy of the completed Field Trip Roster (pg. 7) 3. one copy of the Procedures for Serious Accidents, Emergencies, and Fatalities Form (pg. 9) 4. one copy of the completed Trop Roster and Emergency Contact Information Form (pg.13) 5. one copy of each girl's & adult’s completed Health History Form (pg. 11)

STEP 4: in the pocket of each folder add at least one Insurance Brochure and Insurance Claim Form.

STEP 5: label one of the folders "Emergency Contact Person" and all the others "Driver’s Folder".

**Your folders are now complete! Plan and prepare for your trip using the guidelines that follow and ..... ENJOY THE FIELD TRIP!!!

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Girl Scouts of Southwest Texas

How to... PLAN AND PREPARE FOR THE TRIP

5 weeks before the trip - complete Steps 1- 3

Step 1. With the girls, decide where, when, and how you would like to go. Consider the

following: < Will there be a cost involved and will the troop treasury cover it? < Will you allow girls to bring extra spending money for souvenirs, snacks, etc.? If f yes, what will you < do about the girls who aren't able to bring extra? < What should girls wear or bring with them? (hat, water, long pants, etc.) < Girls should be briefed ahead of time on what to expect (i.e. sometimes nursing homes have a

"funny" smell), what NOT to expect (there is no air conditioning at camp), what behavior is appropriate (no running at the symphony), and some of the hard things, too... they may have to converse quietly while at the library, and remember, the chili you make at camp won't taste JUST like Mom's! Be sure YOUR expectations are realistic, too.

Step 2. The leader should secure: a.) an Emergency Contact Person. b.) enough Drivers and vehicles so each passenger will have a seat belt. c.) a First Aid Kit to take along on the trip, preferably one in each vehicle. d.) a first aid person with current certification in Standard First Aid and Adult/Child CPR (See

Taking Trips, page 39, of the GSSWT Volunteer Handbook, 2007-2008 Edition)

Step 3. The Leader should complete a Troop Activity Notification form*, and turn it in to your Service Unit Director. *This form is required for ALL activities away from the regular meeting place. A copy is included in this packet (see pg. 25).

1-2 weeks before the trip - complete steps 4 - 6

Step 4. Forms to be given out to troop members at least one week (preferably 2 weeks) BEFORE the trip:

a.) Permission Slip to each troop member to be signed and returned before the trip. (Note to Leader: make sure you get these back. Girls not returning a signed Permission Slip CANNOT participate in the field trip. There's nothing worse than having to leave a girl behind. In this case, the Emergency Contact Person should stay with the girl until her parent arrives.)

b.) Health Form to be completed by each adult driver or other adult participant if you don’t already have one.

Step 5. Make additional copies of the permission slip and note the travel information on the back. (See sample included in the back of this packet.) The travel information should include the names of the troop members participating, a map of the route you are planning to take, telephone number at destination or where you can be reached, and the estimated time of arrival and departure. Give copies of this information to:

a.) your Service Unit Director (SUD) or other designated Service Unit representative b.) place a copy in the pocket of the folder marked "Emergency Contact Person" c.) place a copy in each Driver's Folder so each driver will have the name and number of the

emergency contact person. They will also have a map of the route you're planning to travel and directions in case you get separated in traffic.

Step 6. Before the trip, give the folder labeled "Emergency Contact Person" to the person who agreed to be the troop contact. Remind this person that it is extremely important for them to be available by telephone until you have returned from the trip. All the information they will need in case of an emergency is already in the folder!

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Day of the trip - complete Steps 7 - 11

Step 7. On the day of the trip, the leader should give each driver a "Driver's Folder" and include the permission slip of each girl that is RIDING IN THAT DRIVER'S VEHICLE. Again, each driver should only have the permission slips of the girls riding in their car. If you have several vehicles going, the leader should keep a list of which girl is in which vehicle.

Step 8. The driver should double-check the girls riding in her vehicle to be sure she has the correct girls and permission slips. Everyone should have and use a safety belt!

Step 9. The driver should check each girl riding in her vehicle under “TO SITE” on the Field Trip Roster. ONLY CHECK THE GIRLS RIDING IN THAT VEHICLE. The other drivers will check the other girls on their roster. This will help the driver remember which girls she is responsible for and, should an accident occur and the driver be rendered unconscious, it will enable emergency personnel to determine exactly which girls are in the vehicle. Buckle your safety belts and enjoy the trip!

···· Don’t let this be you!

Step 10. For the "From Site (return)" trip the driver should again check the girls in her vehicle on the Field Trip Roster under “FROM SITE”. This will ASSURE that everyone has entered the car for the return trip and no one will be LEFT BEHIND!

DON'T TAKE ANYTHING FOR GRANTED! The troop leader should check roll of all vehicles to assure

that no troop member gets left behind!!!!

Step 11. The leader should collect the "Driver's Folders" and the "Emergency Contact Person" folder as soon as the trip is over. Now, you're already prepared for the next field trip! The only thing you have to do is get new permission slips.

NOTE: Leaders should keep signed permission slips for a one year period.

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How to use this “Driver’s Folder”

Dear Driver,

Thank you for volunteering your time for Girl Scouting today. This “Drivers Folder” will be important as you assist with our troop’s outing. Please take a minute to familiarize yourself with the documents in this folder: � the Field Trip Participant List, � Procedures for Serious Accidents, Emergencies, and Fatalities form, � the completed Troop Roster and Emergency Contact Information form, and � a completed Health History form for each girl and adult participating in the outing.

In the folder pocket you should also find � an insurance claim form, � an insurance brochure, � a copy of the trip permission slip which lists the name and phone number of the

designated Emergency Contact Person, � a map to the intended destination, and � the permission slip for each girl riding in YOUR vehicle.

Here’s how you can help make this trip a success:

1.) Have the girls planning to ride with you enter your vehicle and buckle their safety belts. Remember, you can only transport as many passengers as you have safety belts for!

2.) If not already included in the folder’s pocket, collect the permission slip for each girl in your vehicle from the troop leader and place them in the pocket of this Driver’s Folder.

3.) Check each girl riding in your vehicle under “TO SITE” on the Field Trip Roster. ONLY CHECK THE GIRLS RIDING IN YOUR VEHICLE! The other drivers will check the other girls on their forms. This will help the driver remember which girls she is responsible for and, should an accident occur and the driver be rendered unconscious, it will enable emergency personnel to determine exactly which girls are in the vehicle.

4.) Make sure all safety belts are buckled and enjoy the trip!

5.) For the return trip, the driver should again check off the girls in her vehicle on the Field Trip Participant (Roster) sheet under “FROM SITE”. This will ASSURE that everyone has entered the car for the return trip and no one will be FORGOTTEN.

···· Don’t let this be you! DON'T TAKE ANYTHING FOR GRANTED! Check roll regularly to assure that no troop member gets lost or left behind!!!! Count, count, COUNT!

6.) After the trip, return this Drivers Folder to the Troop Leader.

Thank you again for volunteering your time for Girl Scouting!

Copy and place one in the front of each drivers folder

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PROCEDURES FOR SERIOUS ACCIDENT, EMERGENCY, OR FATALITY

Steps to be followed by person(s) in charge at the scene of an accident:

1. Remain calm.

2. Give priority attention to the injured - provide all possible care.

3. Secure emergency medical services and law enforcement as appropriate. In the event of fatality or serious accident, always notify law enforcement.

4. Do not leave the scene of the accident until the police arrive. If you must leave, retain a responsible person at the scene. See that no disturbance of the victim's surroundings is permitted until law enforcement assumes authority.

5. Report the emergency to the Girl Scout council immediately by calling leadership center at 210-349-2404 or 1-800-580-7247.

6. Make no statements to the media. Refer all media inquires to the council spokesperson. Do not discuss the incident, place any blame or accept liability.

EMERGENCY INFORMATION and NUMBERS

Police/Fire - 911 Poison Control Center – 1-800-222-1222

Contact #’s outside of the 911 area:

Police:( ) Fire:( ) Ambulance:( )

Troop information:

Troop # Service Unit:

Leader's Name:

Address City Zip

Phone: day ( ) Eve ( ) Cell ( )

Troop Emergency Contact Person:

Phone: day ( ) Eve ( ) Cell ( )

The people listed below are familiar with Girl Scouting in your area. Contact them if you need non-emergency assistance.

Service Unit Director:

Phone: day ( ) Eve ( ) Cell ( )

Membership Development Executive:

Phone: day ( ) Eve ( ) Cell ( )

Girl Scouts of Southwest Texas (210) 349-2404 or 1-800-580-7247

811 N. Coker Loop San Antonio, Texas 78216

Monday - Wednesday 8:30am - 5:30pm Thursday 8:30am - 6:30pm Friday 8:30am - 1:00pm 2nd Saturday of each month 9am – 1pm

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Name Age Date of Birth Troop No.

Address

Parent/Guardian Phone ( )

Home Address

Business Address Phone ( )

In Emergency Notify (Name) Relationship

Address Phone ( )

Name of family physician: Phone ( )

Family medical/hospital insurance carrier: Policy/Group/ID No.

Name of Dentist/Orthodontist Phone ( )

If Military, Sponsor’s I.D. Number

Part I: Illnesses and injuries: Chronic or Recurring Illness (check those that apply and give appropriate dates) [ ] None Applicable [ ] Musculoskeletal Disorders [ ] Diabetes [ ] Ear Infection [ ] Asthma [ ] Bleeding/Clotting Disorders [ ] Seizures [ ] Heart Defect/Disease [ ] Hypertension [ ] Other (specify)

Date of last health examination: Were any complicating medical problems noted in last health examination? [ ] Yes [ ] No Is participant currently under the care of a physician or psychologist? [ ] Yes [ ] No

Since last health exam, has participant had: An illness lasting more than five days? [ ] Yes [ ] No Child’s current weight: A serious injury requiring medical attention? [ ] Yes [ ] No (This is required information for Any exposure to a contagious disease? [ ] Yes [ ] No most medications) Any prescription or over-the-counter medication? [ ] Yes [ ] No Treatment in a hospital or emergency room? [ ] Yes [ ] No A surgical operation or fracture? [ ] Yes [ ] No Any restrictions concerning physical activities? [ ] Yes [ ] No

Please explain any "yes" answers to the above questions. Include dates: )

Girl Scouts of Southwest Texas representative(s) have my permission to administer the following to my child::

[ ] Acetaminophen (nonaspirin) [ ] Antacid [ [ Anti-diarrheal [ ] Antihistamine (Benadryl) [ ] Calamine lotion [ ] Antiseptic liquid or ointment [ ] Hydrocortisone cream [ ] Ibuprofen [ ] Non-aerosol insect repellent [ ] Sunscreen [ ] Topical Antibiotic ointment [ ] Other

Part II: Allergies (Check those that apply and specify nature of reaction.) [ ] Animals [ ] Medicines/drugs [ ] Food [ ] Insect stings [ ] Pollen [ ] Hay fever [ ] Other (specify)

Part III: Other health conditions: (Check those that apply) [ ] None applicable [ ] Bed wetting [ ] Emotional disturbances [ ] Constipation [ ] Fainting [ ] Menstrual cramps [ ] Hearing impairment [ ] Motion sickness [ ] Sickle cell trait or disease [ ] Nosebleeds [ ] Special dietary regimen [ ] Sleep disturbances [ ] Wears glasses or contact lenses [ ] Other (specify)

Part IV: Immunization History (Actual dates are required)

Immunization: Year Primary Series Completed Year of Last Booster D.T.P. Diphtheria Pertussis (whooping cough) Tetanus Td Measles Mumps Rubella (German measles) Oral polio Hbpv Tuberculin test (most recent): Result:

Other:

Please explain any items that are checked. Relate any information that may be useful to the Adult-in-Charge regarding any of these health conditions:

Any activities to be encouraged or restricted.

FOR CHILD: I know of no reason(s), other than the information indicated above, why my daughter should not participate in prescribed activities except as noted, and authorize GSSWT representatives to administer emergency medical treatment.

Signature of parent/guardian: Date

FOR ADULT: This health history is correct and I am able to engage in all prescribed activities except as noted.

Signature of adult: Date

ANNUAL UPDATE (child and adult): This Health History Form may be updated annually or as needed. [ ] I have reviewed the above information and my signature indicates that all statements are true to the best of my knowledge

Signature of parent/guardian/self: Date

HEALTH HISTORY RECORD Revised January 2006

To be completed by parents/guardians of girls or by adult members themselves.

• Keep the original for your troop’s permanent file.

• One copy to parents/adult member.

• One travel copy for activities away from troop meeting place.

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Nombre Edad Fecha de nacimiento Tropa #

Dirección

Padre o tutor Teléfono ( )

Dirección

Dirección del trabajo Teléfono ( )

En caso de emergencia avisar a: Relación:

Dirección: Teléfono ( )

Nombre del médico de la familia: Teléfono ( )

Seguro médico/de hospitalización asequrador: Póliza o grupo #

Nombre del Dentista/Ortodencia Teléfono ( )

Si es Militar, numero de identificacion del Patrocinador Part I: Enfermedades y lesiones: Enfermedades crónicas o recurrentes(marcar lo que corresponda y dar las fechas adecuadas) [ ] No Aplicable [ ] Diabetes [ ] Infección de los oidos [ ] Hemorragias/trastornos de la coagulación [ ] Asma [ ] Confulsiones [ ] Hipertensión [ ] Defectos o enfermedades del corazón [ ] Trastornos musculoesqueléticos [ ] Otras (especificar)

Fecha del último examen médico: ¿Se detectó algún problema en el último examen médico? [ ] Si [ ] No ¿La persona que participa está actualmente siendo tratada por un médico o por un psicólogo? [ ] Si [ ] No

Desde el Ultimo examen medico, el participante a tenido: ¿ha tenido una enfermedad de más de cinco dias de duración? [ ] Si [ ] No El peso de la niña: ¿ha tenido una lesión grave que requiera atención médica? [ ] Si [ ] No (Esta informacion se requiere ¿ha estado expuesta a enfermedades contagiosas? [ ] Si [ ] No para algunos medicamentos.) ¿ha tomado medicinas con o sin receta? [ ] Si [ ] No ¿ha sido hospitalizada o tratada en emergencia? [ ] Si [ ] No ¿ha sido operada o ha tenido una fractura? [ ] Si [ ] No ¿tiene alguna restricción en cuanto a actividades fisicas? [ ] Si [ ] No

Favor de explicar cualquier respuesta afirmativa. Dar fechas:

Las representantes de las Girl Scouts of Southwest Texas tienen mi permiso de administrar lo siguiente a mi hija:

[ ] Acetaminofen [ ] Antiacido [ ] Antidiarreico [ ] Antiestaminico (Benadryl) [ ] Locion Caladril [ ] Liquido Antiseptico [ ] Crema Hidrocortizona [ ] Ibuprofen [ ] Antibiotico en ungüento [ ] Bloqueador Solar [ ] Noen Aerosol repelente de insectos [ ] Otro

Part II: Alergias (marcar las que correspondan y especificar la naturaleza de la reacción alérgica) [ ] Animales [ ] Medicinas/medicamentos [ ] Alimentos [ ] Picaduras de insectos [ ] Polen [ ] Fiebre del heno [ ] Otras (especificar)

Part III: Otras problemas de salud: (marcar los que correspondan) [ ] None aplicable [ ] Hemorragia nasal [ ] Orina durante el sueño [ ] Dolores relacionados con la menstruación [ ] Estreñimiento [ ] Problemas de audición [ ] Mareos [ ] Dieta especial [ ] Desmayos [ ] Usa anteojos o lentes de contacto [ ] Disturbios del sueño [ ] Disturbios emocionales [ ] Anemia de células falciformes o portador de células falciformes [ ] Otras (especificar)

Part IV: Registro de vacunas (Fechas actuales requiras) Año en que se complete Año del Vacuna: la primera serie último refuerzo D.T.P. Difteria Pertusis (tos convulsiva) Tétanos Td Sarampión Parotiditis Rubeola Polio oral Hbpv Prueba de tuberculina (la más reciente) Resultado: Otras:

Favor de explicar cualquier respuesta afirmativa y poporcionar cualquier información en relación con estos problemas de salud que pueda ser útil al adulto encargado. Indicar también las actividades que se deben fomentar o restringir.

PARA NIÑO: Yo no se deninguna razon o razones, mas que de la información indicada arriba, el porque mi hija no pueda participar en actividades prescribida excepto aquellas ya notada, y autorizo los representantes de GSSWT que administren cualquier tratamiento medicode emergencia.

Firma del Adulto: Fecha:

PARA ADULTO: Esta forma de historia medica es corecta y puedo participar in toda las actividades prescribadas excepto las ya notada. Firma del Adulto: Fecha:

RENOVARSE ANUALMENTE (niña y adulto): Esta forma de su historia medica pueda renovarse anualmente o cuando haya cambios.

[ ] He revisado toda la información dada y mi firma indica que todo lo dicho es verdadero.

Firma propia o padre o tutor: Fecha:

FORMULARIO DE HISTORIA DE SALUD Reviso enero 2006

Para ser llenado por los padres o tutor de las niñas o por el membro adulto.

• Guarde la original para poner en el archivo de su tropa.

• Una copia para los padres o miembro adulto.

• Una copia para las actividades que requira viajar.

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TROOP ROSTER & EMERGENCY INFORMATION

Service unit: Membership year: -

Troop/group # Level (circle all that apply): Da Br Jr Cd Sr Am Multi-level

Leader's name:

Address: City: Zip:

Phone: Day ( ) Evening ( ) Other ( )

Email:

M.D.E.

Contact # ( ) ( )

Service Unit Director

Contact # ( ) ( )

Instructions: Have each parent complete the personal information for their daughter, including any special needs or circumstances the troop adults should be aware of. Each adult working with the troop should also complete the information requested.

1. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

2. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

Girl Scouts of Southwest Texas P.O. Box 790339 San Antonio, Texas 78279-0339 210.349.2404 or 1.800.580.7247

Location: 811 N. Coker Loop (78216)

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Troop Roster & Emergency Information continued

Instructions: Have each parent complete the personal information for their daughter, including any special needs or circumstances the troop adults should be aware of. Each adult working with the troop should also complete the information requested.

3. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

4. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

5. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

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Troop Roster & Emergency Information continued

Instructions: Have each parent complete the personal information for their daughter, including any special needs or circumstances the troop adults should be aware of. Each adult working with the troop should also complete the information requested.

6. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

7. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

8. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

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Troop Roster & Emergency Information continued

Instructions: Have each parent complete the personal information for their daughter, including any special needs or circumstances the troop adults should be aware of. Each adult working with the troop should also complete the information requested.

9. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

10. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

11. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

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Troop Roster & Emergency Information continued

Instructions: Have each parent complete the personal information for their daughter, including any special needs or circumstances the troop adults should be aware of. Each adult working with the troop should also complete the information requested.

12. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

13. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

14. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

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Troop Roster & Emergency Information continued

Instructions: Have each parent complete the personal information for their daughter, including any special needs or circumstances the troop adults should be aware of. Each adult working with the troop should also complete the information requested.

15. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

16. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

17. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

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Troop Roster & Emergency Information continued

Instructions: Have each parent complete the personal information for their daughter, including any special needs or circumstances the troop adults should be aware of. Each adult working with the troop should also complete the information requested.

18. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

19. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

20. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

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Troop Roster & Emergency Information continued

Instructions: Have each parent complete the personal information for their daughter, including any special needs or circumstances the troop adults should be aware of. Each adult working with the troop should also complete the information requested.

21. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

22. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

23. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

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Troop Roster & Emergency Information continued

Instructions: Have each parent complete the personal information for their daughter, including any special needs or circumstances the troop adults should be aware of. Each adult working with the troop should also complete the information requested.

24. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

25. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

26. Name Birthdate Age

Address City Zip

Home Phone( ) Grade School

Mother’s Name Work #( )

Father’s Name Work #( )

Other Contact # ( ) Email:

Alternate Emergency Contact (to be used only if neither parent can be reached):

Name Relationship to Child

Contact #(s) ( ) ( )

Special Needs/Instructions (list allergies, dietary needs, special circumstances, etc.)

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P.O. Box 790339, San Antonio, TX 78279-0339 (210) 349-2404 or 1-800-580-7247 Fax: (210) 349-2666

Permission Slip

PLEASE KEEP THIS HALF FOR INFORMATION DEAR PARENTS: We want you to know about an activity your daughter's troop is planning which will occur away from the regular meeting place and we need your permission.

Troop No. 1169 is planning a field trip to celebrate the Girl Scout Birthday

located at McDonalds on 7099 Bandera Rd. on (date) March 12, 1991 .

Mode of transportation personal vehicles . Your signature gives permission for her to ride in the

vehicle to be used for transportation.

Time and place of departure Oak Hills Terrace (O.H.T.) Cafeteria

Time and place of return 6:30pm to Oak Hills Terrace. Please pick your daughter up promptly. My

son has a soccer game at 7:00pm.

Adults accompanying the girls Wanda Wehmeyer, Janelle Kock, Terri Smith

Money each girl will need $3.00

Other equipment and clothing appropriate dress for weather

TROOP CONTACT PERSON: (For emergency calls from you or from the troop)

Name Connie Mayfield Phone ( 210 ) 674-8885

Please keep the above for your information, sign and return the bottom portion of this form to the

troop leaders no later than March 7, 1991 .

- - - - - - - - - - - - - - - - - - - - - -RETURN THIS HALF TO LEADER - -- - - - - - - - - - - - - - - - - - - - -

My daughter Keri Wehmeyer has my permission to participate with Troop # 1169

in March 12 trip. . She is in good physical condition and has not had any serious illness or operation since

her last Health Examination. I understand that the activity will be carried out in keeping with the Health and Safety Practices and Standards of Girl Scouts of the U.S.A. Should any accident or illness occur to her on the trip, I shall not hold the leader of the troop, her agents, or the Girl Scouts of Southwest Texas responsible and I authorize the leader to obtain services of a medical doctor, if necessary. The Girl Scouts of Southwest Texas has my permission to use photos or videotapes in which my daughter appears for publicity purposes. Yes T No

During the activity I may be reached at home Phone ( 210 ) 649-2312

If I cannot be reached, please call Gerald Wehemeyer Phone (210 ) 741-0953

Physician's Name Dr. F. Guerra Phone (210 ) 694-1500

Parent's Signature Wanda Wehmeyer Date March 5, 1991

Note: In addition to this form, a medical history signed by the parent within the current year is required for water

sports, horseback riding, skating, hiking, non-contact sports such as tennis or gymnastics and other such physically demanding activities.

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(Back of Permission Slip)

Travel Information

We will take Forest Dell to Evers Rd. Evers to 410 Access Rd and turn right to McDonalds at 7099 Bandera Rd. We will follow the same route back.

Girls on trip:

1. Jennifer Vasquez

2. Keri Wehmeyer

3. Melissa Margo

4. Natalie Griffin

5. Holly Mendoza

6. Lea Gonzales

7. Tammy Holt

8. KIm Fowler

9. Holly Carter

10. Carol Simms

Adults on trip:

Wanda Wehmeyer - driver and leader

Terry Smith - driver and asst. leader

Janelle Kock - SFA and CPR

**NOTE: This is a sample of the regular permission slip with the travel information listed on

the back. A copy of this slip with travel information should be given to:

1.) your Service Unit Director (or M.D.E.) along with the Troop Activity Notification,

2.) place a copy in the folder labeled "Emergency Contact Person" so that if there

would be a problem along the way (car trouble, flat tire, etc), your Emergency Contact

Person will know which route you were planning to travel and can relay that

information to the proper people to aid in the search for you. **The Emergency Contact Person should NEVER leave the phone to search for you, it is extremely important that they remain by the phone at ALL times.**

3.) place a copy in each "Driver's Folder." This way each driver will have the

Emergency Contact person's name and telephone number and, should you become

separated, the drivers will be able to follow the map and reach the destination safely.

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TROOP ACTIVITY NOTIFICATION

To be submitted for approval to Service Unit Director Required for any meeting away from the regular meeting place.

Troop Number: Troop Leader’s Name: Phone Number: (home) (work) (mobile/pager) Emergency Contact Person: Name: Phone Number: Activity: Date(s): Location: Submit to Service Unit Director for approval. A Council-Owned Site Use Application is required for reservation of

Council-owned sites. Additional insurance coverage should be obtained from the Council office for non-members, or for trips of three nights or more. For trips of three or more nights, an Extended Trip Packet must also be completed. TRAINED ADULTS Name Expiration Date

Troop Leadership:

First Aid:

Outdoor Trained:

**Other (Title)

**Examples of other certifications include: OE 3 , OE 4, Lifeguarding, Small Craft Safety.

HEALTH & SAFETY GUIDELINES � Always refer to Safety Wise.

� Secure parental permission before outings.

� The troop must be accompanied by a trained First Aider.

� The adult/girl ratio must be adhered to at all times.

� Adults are selected and supervised by the troop leader.

� Special training or certification is required for some activities.

� Alcohol is strictly prohibited. Firearms are strictly prohibited.

Return bottom portion to Leader

Girl Scouts of Southwest Texas TROOP ACTIVITY NOTIFICATION

Troop Number: Troop Leader’s Name: Activity: Date(s): Location:

Approved by: Service Unit Director Date

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Suggested Field Trips Because there are so many changes in hours of operation and admission fees, we suggest you contact the place itself for this information. Check also to see if reservations are necessary.

NAME LOCATION and/or PHONE AMEDD Medical Museum ............................................................................................... Stanley Road Alamo Heights Nature Trails ................... Must have permission from Chief of Police, Call 822-6433 Botanical Center .............................................................................................................. 555 Funston Brackenridge Park ......................................................................................... Mulberry & N. St. Mary's Buckhorn Museum .......................................................................... 318 Houston St., (210) 247-4000 Cave Without a Name...................................................................................... Boerne: 830-537-4212 Dos Rios Water Recycling .................................................................................................... 704-7601 Espada Acequia Aqueduct ................................................................................... 9044 Espada Road Ft. Sam Houston Military Museum ............................................................ 207 Stanley Rd., Bldg. 123 Fredrich Park ........................................................................................... IH 10 W. (Camp Bullis Exit) Great Harvest Bread Company ............................................. 2267 NW Military Hwy., (210)348-9870 Hall of Texas History Museum .................................................. Lone Star Pavillion (Hemisfair Plaza) Hangar 9 .......................................................................................................... Brooks Air Force Base Hemisfair Plaza ..................................................................................... Downtown at Market & Alamo Hertzberg Circus Collection .......................................................................................... 210 W. Market Institute of Mexican Cultures ....................................................................... 600 Hemisfair Plaza Way Institute of Texan Cultures ................................................ 210 S. Bowie at Durango, (210) 458-2291 Japanese Sunken Gardens .................................................................................... 3875 N. St. Mary's KENS TV ........................................................................... 5400 Fredericksburg Rd., (210) 366-5000 KMOL TV ..................................................................................................................... (210) 226-4444 La Villita .................................................................................................... Entrance - 416 Villita Street Lighthouse for the Blind ................................................................. 2305 Roosevelt (Age 7 and older) Lonestar Trolleys ......................................................................................................... (210) 222-9090 Main Library ..................................................................................................................... 600 Soledad Main Post Office .......................................................... Perrin-Beitel Rd., 368-1634, Age 10 and older Market Square ....................................................................................................... 514 W. Commerce McNay Art Institute ......................................................................... 6000 N. New Braunfels, 824-5368 Mission Concepcion .................................................................................. 800 Block of Mission Road Mission Espada ................................................................................................... End of Espada Road Mission San Jose ................................................................................................ 6539 San Jose Drive Mission San Juan Capistrano ............................................................................................. 9101 Graff Ripley’s Believe It or Not .............................................................................................. (210) 224-9299 San Antonio Children’s Museum ................................................................................. (210) 212-4453 San Antonio Museum of Art ............................................................................. 200 W. James Avenue San Antonio Museum of Transportation ............................................................. Hemisfair Plaza Way San Antonio Water Systems ................................................................................................. 704-7297 San Antonio Zoo ..................................................................................................... 3903 N. St. Mary's San Fernando Cathedral .............................................................................. West Side of Main Plaza Scobee Planetarium at S.A.C ......................................................... 1300 San Pedro, (210) 733-2910 Spanish Governor's Palace ..................................................................................... 106 Military Plaza The Alamo ........................................................................................................................ Alamo Plaza The Jose Navarro State ........................................................................ Site228 S. Laredo, 226-4801 The Quadrangle ................................................................... Ft. Sam Houston (enter Grayson Street) Tours of Edwards Aquifer Tower of the Americas ................................................................................................ Hemisfair Plaza USS Lexington Live Aboard Program .......................................................................... (800) 523-9539 Waste Treatment Plant ............................................................................................ 3225 Valley Road Wild Animal Orphanage ............................................................................................... (210) 688-9038 Witte Museum ........................................................................................................ 3801 Broadway

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Have a safe trip!

WW / rev 8/2007