Daughter Name:__________________________________________

Has my permission to leave the regular troop meeting in ___________________________________________ to go outside on the grounds of the meeting place to do troop activities.

Can return home from meetings by the following means (check all appropriate). __________ mother/father/guardian will pick her up __________ is allowed to go home with fellow Girl Scout, __________ is allowed to walk home

________ anytime ________ alone ________ with ___________________ ________ other___________________

__________ is NOT allowed to leave with ___________________________________________________ __________ List of family members or friends that might pick her up:

________________________________________________________________________________________ _____________________________________________________________________________________ ________________________________________________________________________________________ Please list any medical condition we should be aware of such as asthma, allergies (food or medicine or insect bites), etc. If any medication is needed to be taken by your daughter during the meeting time or at any Girl Scout activity, please inform the leaders and provide written instructions with the medication.

________________________________________________________________________________________ ________________________________________________________________________________________ Special dietary needs: ______________________________________________________________________ ________________________________________________________________________________________

Parent’s signature: ________________________________ Date: __________________________________

--turn over-1

MEDIA RELEASE FOR MINORS For Troop Meetings and Activities from ______________ to _____________ Girl Scout year.

For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent and agree to the following: 1. I hereby grant to Girl Scouts of the USA (“GSUSA”) and Girl Scouts of Central & Southern NJ (GSCSNJ) and others working for GSUSA/GSCSNJ or on its behalf, and each of its respective licensees, successors and assigns (each a “Releasee”), the irrevocable, royalty-free, perpetual, unlimited right and permission to use, distribute, publish, exhibit, digitize, broadcast, display, modify, create derivative works of, reproduce or otherwise exploit my name, picture, likeness and voice (including any video footage of the same) (collectively, “Media”), or to refrain from so doing, anywhere in the world, by any persons or entities deemed appropriate by GSUSA/GSCSNJ, for any purpose (except defamatory) including, without limitation, any use for educational, advertising, noncommercial or commercial purposes in any manner or media whatsoever (whether known or hereafter devised) including, without limitation, on the internet, in print campaigns, in-store and via television. I agree that I have no interest or ownership in any of the Media. 2. I shall have no right of approval, no claim to compensation and no claim (including, without limitation, claims based upon invasion of privacy, defamation or right of publicity) arising out of any use, alteration, blurring, illusionary effect or use in any composite form of my name, picture, likeness and voice. I agree that nothing in this Release will create any obligation on GSUSA/GSCSNJ to make any use of the Media or the rights granted in this Release. I hereby release and hold harmless Releasees from any claim for injury, compensation or negligence resulting or arising from any activities authorized by this Release and any use of the Media by GSUSA/GSCSNJ.

NAME OF MINOR (please print):______________________________________________________________________ ADDRESS:_______________________________________________________________________________________ CITY_______________________________________________ STATE_________________________ ZIP__________ DAYTIME PHONE NUMBER: (_____)________________ ADDITIONAL PHONE (optional) (____)__________________

Release for Minors (those under the age of eighteen): I, the undersigned, being a parent or guardian of the minor, hereby consent to the foregoing conditions and warrant that I have the authority to give such consent.

NAME OF PARENT/LEGAL GUARDIAN (please print):_____________________________________________________ SIGNATURE OF PARENT/LEGAL GUARDIAN (REQUIRED):_______________________________________________ DATE:___________________________________________________________________________________________ PARENT/LEGAL GUARDIAN EMAIL ADDRESS*:___________________________@____________________________ (*will not be used for any other purposes or distributed to third parties)


blanket permission form - Girl Scout troop # 72833

______ List of family members or friends that might pick her up: Please list any medical condition we should be aware of such as asthma, allergies ... ADDRESS: ...

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