Fall 2021 Inspire Discovery

Fall 2021 Individual Activity Application

Registrant Name — —————————————————————

Disability Information: Girl Scouts of Eastern Missouri welcomes the participation of all girls and adults and will make reasonable accommodations for persons with disabilities. If you have questions or if you want to discuss an accommodation, please contact the Answer Center at 314.400.4600 or answercenter@girlscoutsem.org . Does your child need a reasonable accommodation? �Yes � No Describe: — ——————————————————————————— Method of Payment — all monies received are cashed or charged when received by Girl Scouts of Eastern Missouri. Check all that apply: � Check or Money Order � Debit Card � Visa � MasterCard � Discover A) Program Fee Amount $ — ————————————————— B) Charitable Gift Enclosed $ — ——————————————— C) Total Fee (A+B) $ —————————————————————— Credit Card Information Account # — ————————————— Exp. Date —————— Cardholder’s Signature ———————————————————— Date ———————————————————————————————

Address ———————————————————————————

City — —————————————— State ———— ZIP — ————

Primary Phone — ——————— Cell Phone — ————————

Email — ———————————————————————————

Parent/Guardian Email — ——————————————————

Current Program Level (circle) D B J C S A Adult

Current Grade — ——————————————————————

Troop # — ————————————————————————————

District/Neighborhood — ——————————————————

Racial Ethnic Background (optional)

The following information is requested only to measure progress toward serving all girls in our jurisdiction. � White � Black � Asian � Hawaiian/Pacific Islander � Hispanic � American Indian/Alaskan Native � Other

Dietary Requirements: — ——————————————————

� Flowers � Gold Award Review Night � Gold Award Training � Great Gardeners � Hour of Code: Brownies � Hour of Code: Daisies � How Robots Move for Daisies

I am registering for: � aMAZE Journey � aMUSE Journey � Astronomy Club � Babysitter Boot Camp � Balloon Care Design Challenge � Bow and Arrow Club � Brownie Automotive Engineering Design � Brownie Cybersecurity Basics � Brownie Digital Leadership � Brownie Disability Awareness � Brownie Shapes in Nature � Brownies, Butterflies and Bugs! � Cadette Cybersecurity Safeguards � Cadette Digital Leadership � Car Care � Citizenship and Me � Comic Artist � Comparison Shopping � Democracy for Brownies � Democracy for Daisies � Democracy for Juniors � Designing Robots for Daisies � Draw with Me � Edward Jones Cookie College � Engineering Adventures: Crane Design Challenge � Extreme Team � Fall Equestrian Programs � Daisy Cybersecurity Basics � Daisy Disability Awareness � Daisy Flower Garden

� Observe the Night Moon at Jefferson College Observatory � Outdoor Adventurer Badge � Philanthropist for Brownies � Product Designer � Robot Ruckus � Robotics Showcase � Senior/Ambassador Cybersecurity Basics � Shapes in Nature � Snack Hacks � So You Want to be a Screenwriter?

� Introduce a Girl to Engineering Night � James Webb Space Telescope Launch Event � Juliette Gordon Low’s Birthday Bash

� Junior Automotive Design � Junior Digital Leadership � Junior Disability Awareness

� Space Science Adventurer � Space Science Researcher � Super Scout Swag � SWENext Club � Textile Artist � The Science of Happiness

� Junior Jeweler � Junior Scribe

� Junior Shapes in Nature � Leap Bot Design Challenge � Letterboxer � Making Friends � Making Games � Maple Syrup � MEdia Journey � Meet the Highest Awards � MISSION: Sisterhood � My Best Self � My Cookie Customer � My Cookie Team � My Cookie Venture � Netiquette � New Cuisines � Novelist

� Think Like a Citizen Scientist � Think Like an Engineer Journey � Think Like an Engineer Journey Day � Three Cheers for Animals Journey � Trail Adventure Badge � Trees � Winter GAM � World of Girls Journey � You Can Dance, You Can Jive � Your Voice, Your World Journey

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