Summer 2021 Inspire Discovery

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Summer 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: — ——————————————————

I am registering for: � Agent of Change Journey � aMAZE Journey � Ambassador First Aid and Safety Pin

� Crane Design Challenge � Daisy and Brownie Think Like a Programmer Journey � Daisy Safety Pin � Eating for You � Get Moving Journey � Gold Award Review Night � GirlTOPIA Journey � How Robots Move for Daisies � Junior Think Like a Programmer Journey � LEGOs, Robots and Badges -Oh My! � Meet the Highest Awards � More than LEGOs: The Building Blocks of Robotics

� Perseid Meteor Shower Overnight � Science of Style � Senior First Aid and Safety Pin � Sensational Senses � Soar Into STEM with Wings of Hope � Sow What Journey � Space Science Investigator � Super Savers � The Ghost of Pandora’s Manor � Think Like a Citizen Scientist at Hawn State Park � Virtual Chat with NASA’s Artemis Team � Wings of Hope Aviation Day

� Animal Habitats � Artist for a Day � Bliss—Live it! Give It! � Book Artist � Breathe Journey

� Brownie Quest Journey � Brownie Trail Adventure � Business Etiquette � Business Plan � Cadette Think Like a Programmer Journey

34 Inspire Discovery Spring 2021

34 Inspire Discovery Summer 2021