Traveler Information Form
Adult Participant

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Girl Scouts are going places! Please complete the form below for your upcoming council-sponsored trip to ensure a safe trip.

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

Trip Information

Trip Name: *

Departure Date: * +

Contact 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.

First Name: *

Middle Name:

Last Name: *

Date Of Birth: * +

Sex: * 🛈

T-shirt Size: *

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.

First Name: *

Last Name: *

Phone: *

Relationship: *

Health Information

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: *

Recommended Vaccines Current? * 🛈

Tetanus/DPT Vaccine Current? *

If you are unsure of your current vaccinations, please contact your primary healthcare provider before submitting this form.

List Prescription Medications (Include Dosages): *

List Dietary Restrictions: *

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 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.

Signature: *

clear

Date: *

Acknowledgement

I give 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 I appear may be used for promotional purposes. I certify that: I am in good health, have 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, I may be treated by a designated First Aider and/or medical/hospital personnel. In the event I am incapacitated in an emergency, I hereby give permission to the physician selected by designated Girl Scout staff to hospitalize and secure proper treatment for me. 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.