DUE TWO WEEKS BEFORE ACTIVITY
IMPORTANT: READ THIS INFORMATION (PDF) BEFORE SUBMITTING YOUR ACTIVITY APPLICATION FORM.
Is this a: Service Unit Activity Troop Activity
Is this a: Day Trip (Complete Part A) Overnight/Camping (1-2 nights, Complete Parts A & B)
Service Unit: Troop Number(s): Program Level Select One Daisy Brownie Junior Cadette Senior Ambassador Multiple
Name of person submitting form Email of person submitting form Address: City: State: ZIP Code:
Day Phone: Evening Phone: Cell:
Certifications: Troop Camper First Aider Additional Certified Adult(s), i.e. lifeguards (attach certification)
Name: Phone: Certificate Expires:
Is additional insurance for non-members needed? No Yes (If so, please contact GSEM) This is needed when any non-Scout participates in an activity.
By checking this box I confirm that I have reviewed the Safety-Wise requirements that apply to my event/trip. Please list pages:
Must be completed for all types of activities.
Date of Event: Destination: Program Description:
Participants: # of girls # of women # of men All adults having contact with children need to be CORI'd and registered.
Mode of Transportation:
Have Bus/Van contracts been approved by GSEM? No Yes All contracts need to be reviewed by GSEM Directors before they can be signed.
Is there a current certificate of liability on file with GSEM for activities requiring one? No Yes Certificates of Liability Insurance need to be supplied when specified in Safety-Wise for proof of insurance or when GSEM requests one.
Lodging Arrival Date/Time Departure Date/Time
Emergency Contact During Trip: Emergency Contact Phone Number:
Type of Money Earning Activity:
How much do you plan to raise?
Purpose:
Will the troop participate in this year's cookie sale?No Yes If no, why?:
By clicking "Send", I certify that the information on this form is true, correct, and complete.
