Spring 2022 Inspire Discovery

Spring 2022 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: — ——————————————————

I am registering for:

� Agent of Change Journey � Ambassador Eco Advocate � Artist for a Day � Astronomy Overnight - Girl Scouts Love State Parks � Bronze Award Training � Brownie STEM Career Exploration � Brownie Shapes in Nature Trail Adventure � Buddy Camper � Cadette Camp-A-Rama � Cadette Trail Adventure � Current River Camp and Canoe � Daisy Between Earth and Sky Journey � Daisy DIY � Daisy Roller Coaster Design Challenge � Daisy Safety Pin

� Girl Scouts Love State Parks � GIRLtopia Journey � Gold Award Training � GSEM Goes to Space Camp � Ice Cream Day � Junior Cybersecurity Basics � Junior Road Trip � Junior Programming Party

Cedarledge BioBlitz � Think Like an Engineer - Multilevel � Think Like a Programmer-Cadette � Think Like a Programmer-Daisy/ Brownie � Think Like a Programmer-Junior � Three Cheers for Animals Journey � Urban Archery � Volunteer Day at Gateway Arch National Park - River Cleanup � Volunteer Day at Gateway Arch National Park - Tree Promise � Urban Archery � Wings of Hope Aviation Day

� Junior Outdoor Journey - Overnight � Junior Trail Adventure - Girl Scouts Love State Parks � LEGO, Robots and Brownies-Oh My! � MEdia Journey Overnight � Missouri From Bottom to Top � Outdoor Adventurer-Girl Scouts Love State Parks � Pack the Creek � Robotics Showcase � Senior and Ambassador Journey Overnight � Senior Eco Explorer � Silver Award Training � Soar Into STEM Exploration � So, You Want To Be a Screenwriter? � Sow What? Journey � Sun Day on a Sunday � Think Like a Citizen Scientist- Camp

� Women in the Outdoors � Woodworking Workshop

� Daisy Shapes in Nature � Democracy for Daisies � Design Thinking Workshop � Detective � Digital Movie Maker � Digital Photographer � Eating For You � Empowerment Project � Flowers with Urban Buds

Inspire Discovery Spring 2022 65