Spring 2021 Inspire Discovery

Individual Activity Application

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 — ————————————————————————————————————————

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

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: ——————————————————————————

I am applying for: (Check only one)

� Animal Habitats � Board Game Design Challenge for Daisies � Bodies and Minds � Book Artist � Buddy Camper � Bugs � Business Etiquette � Business Plan � Cadette Camp-A-Rama � Cadette Chopped Challenge � Cadette Cybersecurity Basics � Cadette Engineering Career Exploration � Cadette MEdia Journey � Cadette Outdoor Art � Camp CEO � Camp Fiddlecreek Star Party

� Gold Award Boot Camp � Gold Award Candidate Training � High School Chopped Challenge � High School Outdoor Art � How Robots Move for Daisies � Introduce a Girl to Engineering Day � Junior First Aid � My Best Self � Outdoor Journey Weekend � Pack the Creek � Paddleboard Design Challenge for Juniors � Philanthropy for Brownies � Programming Robots for Brownies � Savvy Shopper � Science of Style � Senior Journey Mission: Sisterhood

� Camp Tuckaho Star Part � Crane Design Challenge � Daisy Cybersecurity Basics � Daisy Safety Pin � Digital Movie Maker � Disability Awareness � Fling Flyer Launch � Girl Scout Birthday Celebration

� Space Science Adventurer � Space Science Investigator � Spring Equestrian Program � Think Like a Citizen Scientist Journey � Think Like a Citizen Scientist-City Nature Challenge for Cadettes � Think Like a Citizen Scientist-City Nature Challenge for Seniors and Ambassadors

Inspire Discovery Spring 2021 55