Traveler Information Form
Girl Participant

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Girl Scouts are going places! Parents/caregivers, to ensure a safe experience, answer all questions below for your girl traveler. Additionally, girls participating in council-sponsored trips—of four nights or more—must submit a physical exam form that has been completed within 12 months of the trip dates and signed by a physician.

If you have any questions, please email us or call 402.558.8189.

Trip Information

Trip Name: *

Departure Date: * +

Girl Information

For travelers required to show TSA-approved ID at airport security (18 and older at the time of travel), list all names exactly as they appear on the traveler's ID.

Girl First Name: *

Girl Middle Name:

Girl Last Name: *

Date Of Birth: * +

Current Grade: *

Cell Phone:

T-shirt Size: *

Travel Experience: *

1. Has She Ever Traveled With A Group?
2. Has She Ever Traveled Solo?
3. Has She Ever Flown On An Airplane?

Please Describe Her Past Travel Experiences: *

Parent/Caregiver Contact Information

Parent/Caregiver First Name: *

Parent/Caregiver Last Name: *

Street Address: *

Apt. #:

City: *

State: *

ZIP Code: *

Phone: *

Email: *

Emergency Information

Please provide the name and contact information of a family member, friend, or healthcare proxy who can be reached in case of an emergency. The emergency contact for girl participants must be someone other than the parent/caregiver listed above.

First Name: *

Last Name: *

Phone: *

Relationship to Child: *

Health Information

All participants must complete the Health Information questions below. Additionally, girls participating in council-sponsored trips—of four nights or more—must submit a physical exam form that has been completed within 12 months of the trip dates and signed by a physician. You may provide a scan or photo of the completed record or use this form.

Upload Physical Examination Form:

Physician Name: *

Name of Practice:

Physician Phone: *

Date of Last Health Exam: * +

List Any Medical Problems Noted During Last Health Exam: *

Health Condition(s) To Consider For Activities: *

Specify Other: *

Allergies: *

Specify Drug Allergy: *

Specify Food Allergy: *

List Hospitalizations (Include Dates): *

List Operations or Serious Injuries (Include Dates): *

Immunizations: * 🛈

	Date Administered
DPT	Date Administered
Measles	Date Administered
MMR	Date Administered
Mumps	Date Administered
Polio	Date Administered
PT	Date Administered
TB Test	Date Administered
Tetanus	Date Administered
Rubella	Date Administered

List Prescription Medications (Include Dosages): *

Over-the-Counter Medication(s): *

Aspirin
Benadryl
Ibuprofen
Tylenol

List Dietary Restrictions: *

Life-Changing Event(s): *

Has Menstruation Been Discussed? *

Specify Other: *

Is There Anything Else We Need to Know?

Code of Conduct Agreement

Girl Scouts Spirit of Nebraska council-sponsored trips require a significant amount of personal responsibility and independent decision-making from all volunteers and participants. To maximize the health and safety of program participants, Girl Scouts Spirit of Nebraska requires all adults and girl participants to adhere to the Spirit of Nebraska Travel Code of Conduct.

Trip Participants will:

Abide by the Girl Scout Promise and Law.
Treat other participants and the people they meet with respect.
Follow the directions of the adult Trip Advisors and immediately report any problems or concerns to them so they may be resolved.
Participate in all group activities to the fullest of their ability.
Travel with a sense of wonder and spirit of adventure.

Trip Participants will not:

Engage in any behavior that may be harmful to the health and safety of themselves or others.
Engage in any behavior that may be detrimental to the program.
Use or possess any drugs, which are illegal under the laws of the United States or of the host country.
Consume alcoholic beverages.
Leave the assigned program area or the group without permission from an adult advisor on the trip.
Handle firearms.
Use tobacco products, if under the age of 19.

I/we have read the above Travel Program Code of Conduct and agree to abide by the Code of Conduct at all times during the trip. I understand and acknowledge that I am responsible for myself and the choices I make, and if I choose to do something that endangers myself, other participants, or knowingly goes against this agreement, I will be dismissed from the program and sent home at my own expense.

Parent/Caregiver Signature: *

clear

Date: *

Girl Signature: *

clear

Date: *

Parent/Caregiver Acknowledgement

My child has my permission to participate on the trip listed above and any activities listed on the trip agenda. I will otherwise notify the council in writing if my child does not have my permission to participate in a specific activity. My child has my permission to use transportation (private and/or public) selected by Girl Scout staff. I understand that I am responsible for arranging transportation to and from the trip departure location, unless otherwise specified. I understand that photos in which my child appears may be used for promotional purposes. I certify that: my child is in good health, has not been recently exposed to any contagious diseases, and the information I have provided on this form is correct to the best of my knowledge. In the event of illness, injury, or medical emergency, my child may be treated by a designated First Aider and/or medical/hospital personnel. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by designated Girl Scout staff to hospitalize and secure proper treatment for my child. I understand that for independent-level council-sponsored trips, prescription medications are given to First Aiders for distribution. I understand the insurance carried by Girl Scouts is accident secondary coverage.

I HAVE REVIEWED ALL NECESSARY INFORMATION AND AGREE TO ABIDE BY ALL REGULATIONS.

Parent/Caregiver Signature: *

clear

Date: *

Traveler Information FormGirl Participant

Save & Return

Trip Information

Girl Information

Parent/Caregiver Contact Information

Emergency Information

Health Information

Code of Conduct Agreement

Parent/Caregiver Acknowledgement

Traveler Information Form
Girl Participant