GSCM FORMS
Rev. 05/11/2020
Page 1 of 7
Extended Overnight
Trip Application
For trips of 3+ consecutive nights
NOT to be used for Council-sponsored trips of any length OR trips of 2 or less consecutive nights
Application must be submitted to council via membercare@gscm.org
.
This checklist is intended to help organize forms that will need to be completed prior to departure.
Please use this form as a planning checklist as the troop plans their trip.
❑
Extended Overnight Trip Application Packet.
This multi-page form must be submitted for all
overnight trips of 3+ nights or to a location that is 250+ miles from the troop’s designated
meeting location. Filing timelines are as follows:
o
45+ days prior to the planned start date of any trip to a location that is within the
continental United States and further than 250 miles from the troop/groups’s designated
meeting location, as reflected in the files of council.
o
90+ days prior to the planned start date of any trip to a location that is outside the
continental United States.
❑
Adult Certifications
o
All participating adults must be a registered Girl Scout and have a current and approved
Criminal Background Check on file with Council.
o
All Safety Activity Checkpoints and ratios must be followed.
o
CPR/First Aid must be obtained by an acceptable number of Approved Adults as required
by GSUSA adult to girl ratios.
o
The designated Trip Leader must have successfully completed required Camp and/or Travel
Training.
❑
Girl Information (per attending girl)
o
Girl and Adult Health History Record
o
Parent/Guardian Permission for Girl Scout Activities, Trips and Events
❑
Adult Information (per attending adult)
o
Girl and Adult Health History Record
o
Copies of Driver License and Insurance Card for all drivers*
❑
Personal Conduct
o
Program Event Code of Conduct signed by each girl and adult participant.
❑
Additional Insurance
❑
Non-Continental US Travel Forms Packet
o
Applicable only to travel outside the Continental United States
Once Travel Checklist is complete leave a copy with:
Emergency Contact:
Phone Number:
The Extended Overnight Trip Application must be completed for all travel activities, including trips to
Girl Scouts of Central Maryland Properties. This application is not to be used for Council-sponsored
trips of any length OR trips consisting of two or less consecutive nights. Applications must be
submitted for GSCM review via membercare@gscm.org. You will be notified in writing if your trip has
been approved or denied. This form must be approved before anyone may depart for the trip. If girls
will be participating in additional money-earning activities, this form must be approved before such
activities may be approved.
Trip Leader: _________________ Troop: _____________________ Service Unit: ________________
Email: _____________________ Phone: ____________________
Program Level(s):
Junior Cadette
Senior Ambassador
Number of Girls: _____________ Number of Adults: ____________
Destination: _________________ Trip Dates: _________________ Purpose of Travel: ____________
Participant Information:
*Daisies and Brownies may NOT participate in Extended Overnight Trips
Adult (Role):
Required:
Leader/Trip Advisor
1
st
Aider
Name:
Girls (Level*)
Junior, Cadette,
Senior or
Ambassador
Name:
Required Certifications
(Must list a 1
st
Aider (or WFA/WFR)
and
Trip (Level I, II or III)
or
Camp (Tent or Backpacked) Trained Individual)
List adults participating in this trip who have completed the designated required trip trainings.
Name
Certification/Licensure
1
st
Aid
Camp
Travel I
Travel III
WFA/WFR
Tent
Travel II
Backpacking
1
st
Aid
Camp
Travel I
Travel III
WFA/WFR
Tent
Travel II
Backpacking
Itinerary and Safety Activity Checkpoints
List basic activities planned for this trip: __________________________________________
__________________________________________________________________________
_________________________________________________________________________.
Are there high-risk activities* on this trip? Yes No If yes, explain:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________.
* Additional Insurance may be Required
Is a certified instructor or facilitator required for any of the activities? Yes No
If YES, complete the chart below:
(Include both paid contractors and Girl Scout volunteers)
Instructor/Facilitator
Certification
(Complete for each
Instructor/Facilitator)
Company Name
(Complete ONLY for non-
Girl Scout Volunteers)
Company Contact
(Name, Phone & Email)
Insurance Info.
(Provide COI, unless
Company is an approved
Girl Scout Partner)
Transportation
Use Additional Sheets If Necessary
Mode of Transportation (select all that apply):
Personal Car
Rental Car – Company: _______________________________________________________
Driver’s
Name
D.L. # Insurance Co
Policy #
Bus – Company: ____________________________________________________________________________
Departure Place/Time
Bus No. (if applicable)
Company Address and
Phone
Company Contact
Insurance
(P
rivate bus, include contract and
COI)
Train – Company: ___________________________________________________________________________
Reservation No.
Train Number
Departure City/Time
Arrival City/Time
Plane – Company: ___________________________________________________________________________
Reservation No.
Flight Number
Departure City/Time
Arrival City/Time
Watercraft – Company: _______________________________________________________________________
Reservation No.
Cabin Nos. (if applicable)
Itinerary
Insurance (Watercraft other
than Cruise Ships)
BUDGET
Troop earned funds may only be used to pay for girls and adults required to meet ratios.
Income:
Troop funds allocated for Trip
$
Funds to be paid by Girls
$__________per girl X __________ of girls
$
Funds to be paid by Required Adults
$__________per adult X __________ of adults
$
Funds to be paid by Optional Adults
(Troop earned funds may not be used to pay for travel of
adults not required to attend to satisfy ratio requirements).
$__________per add’l
adult
X __________ of add’l
adults
$
TOTAL INCOME
$
Expenses:
Total Daily Planner Sheet 1
$
Total Daily Planner Sheet 2
$
Total Daily Planner Sheet 3
$
Total Daily Planner Sheet 4
$
Total Daily Planner Sheet 5
$
Total Daily Planner Sheet 6
$
Total Daily Planner Sheet 7
$
Total Daily Planner Sheet 8
$
Total Daily Planner Sheet 9
$
Total Daily Planner Sheet 10
$
Total Daily Planner Sheet 11
$
Total Daily Planner Sheet 12
$
Total Daily Planner Sheet 13
$
Total Daily Planner Sheet 14
$
Total Daily Planner Sheet 15
$
Total Daily Planner Sheet 16
$
Total Daily Planner Sheet 17
$
Total Daily Planner Sheet 18
$
Total Daily Planner Sheet 19
$
Total Daily Planner Sheet 20
$
Total Daily Planner Sheet 21
$
TOTAL DAILY EXPENSES
$
BALANCE TO EARNED THROUGH
ADDITIONAL MONEY-EARNING
$
Estimated Additional Money-Earing Activities:
(submit required Additional Money-Earning Approval Form for each event)
Event 1: _________________________
Event 2: _________________________
Event 3: _________________________
Event 4: _________________________
Event 5: _________________________
Advisor/Leader Statement of Compliance:
❑
Girl Scouts of Central Maryland Safety Activity Checkpoints, policies and procedures have
been reviewed and will be followed.
❑
All adult attendees are approved Girl Scouts of Central Maryland volunteers. Girl Scout
memberships and criminal background checks will remain valid through the duration of the trip.
❑
All drivers for these activities are properly licensed and all vehicles are registered, insured,
maintained and have a legal seat and seatbelt for every passenger.
❑
Parents/guardians are informed of the trip activities, safety and emergency procedures, contact
information and have completed all required health and safety documents for each girl.
❑
The troop/group will always conduct themselves in a positive manner while representing Girl
Scouts.
ACKNOWLEDGMENT OF RESPONSIBILITIES
I certify that the information in this Extended Overnight Trip Application Packet is correct and current
to the best of my knowledge. I have attached all required forms and understand that I must notify,
and receive written acknowledgement from, Girl Scouts of Central Maryland of any changes to our
submitted plan. I have reviewed the GSCM Safety Activity Checkpoints and Volunteer Essentials
for my planned trip. I understand that Troop funds are to be used only for Troop members—
registered girls and Adults necessary to satisfy ratio requirements.
I also understand that during the trip each vehicle and lead adult of any group of girls will have a
resource packet containing the following:
❑
Health History Record for each person (girls and adults);
❑
Parent/Guardian Permission for Girl Scout Activities, Trips and Events, for each girl;
❑
Roster of participants with emergency contact information;
❑
Itinerary; and
❑
First aid kit and emergency procedure information.
I understand providing misinformation could result in the trip not being covered by Girl Scout
Activity Insurance and could increase personal liability.
Trip Leader Signature: Date:
COUNCIL USE ONLY
DATE RECEIVED:
DATE APPROVED:
DATE DENIED:
IF DENIED, REASON:
DATE OF NOTIFICATION: COUNCIL SIGNATURE:
NEXT STEPS/RECOMMENDATIONS/COMMENTS:
Participant Roster
(Complete additional forms until all participants are listed.)
If any changes are made to this list a new form must be submitted to Council prior to departure.
Troop Emergency Contacts
Emergency Contact at Home (non-traveling individual to relay information to families if necessary)
Name: Phone:
Emergency Contact at Destination (traveling individual designated to relay information to home)
Name: Phone:
Adult Participants
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Girl Participants
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
Participant Name:
Emergency Contact #1
Emergency Contact #2
Name:
Phone:
Name:
Phone:
COUNCIL USE ONLY
DATE RECEIVED:
COUNCIL SIGNATURE:
DAILY TRIP PLANNER
Use a separate sheet for each day. If there is a change, Council notification is required.
[Day/Date]
COST PER PERSON
COST FOR GROUP
MORNING
TRAVEL
Walk Bike Public Transport Taxi Personal Car
Other
Factor in rental cost, gas, fares, taxes, gratuity, etc.
$
$
Meal
Eat-In
Eat-Out
Consider cost of food, taxes, gratuity, etc.
$
$
Activity
(Note equipment needed and instructor, if applicable):
Factor in equipment rental, instructor charges, gratuities, etc.
$
$
AFTERNOON
TRAVEL
Walk Bike Public Transport Taxi Personal Car
Other
Factor in rental cost, gas, fares, taxes, gratuity, etc.
$
$
Meal
Eat-In
Eat-Out
Consider cost of food, taxes, gratuity, etc.
$
$
Activity (Note equipment needed and instructor, if applicable):
Factor in equipment rental, instructor charges, gratuities, etc.
$
$
EVENING
TRAVEL
Walk Bike Public Transport Taxi Personal Car
Other
Factor in rental cost, gas, fares, taxes, gratuity, etc.
$
$
Meal
Eat-In
Eat-Out
Consider cost of food, taxes, gratuity, etc.
$
$
Activity
(Note equipment needed and instructor, if applicable):
Factor in equipment rental, instructor charges, gratuities, etc.
$
$
LODGING
Campsite
Hotel
Watercraft
Other
Location:
______________________________________
Factor in taxes, fees, gratuities etc.
$
$
TOTAL EXPENSES FOR THE DAY
$
$
Code of Conduct Agreement
Attendees will:
◆
act and speak positively to each other, volunteers, facilitators, drivers and instructors;
◆
respect the people and places with which they come in contact;
◆
set a positive example and act as a role model for others;
◆
treat everyone with respect at all times; and
◆
abide by the Girl Scout Promise and Law.
This includes, but is not limited to:
◆
respect for the belonging of others;
◆
respect for facilities and equipment;
◆
respect for the feelings and privacy of others;
◆
respect for leave no trace guidelines; and
◆
respect for the effort that has gone into programmatic offerings.
Attendees must:
◆
agree to accept their share of daily kapers;
◆
agree actively participate in, or try, all activities;
◆
agree to follow all safety procedures including, but not limited to, the buddy system, chaperone
oversight and night-time requirements.
The following behaviors are considered serious and will result in one or more of
the following: (1) loss of privileges, (2) contact with parent/guardian, (3) expulsion
from programs and/or future Girl Scout programs.
◆
threatening harm to self or others;
◆
verbal abuse of another, including the use of profane language or gestures;
◆
physical abuse of another;
◆
destroying property of another; and
◆
behavior that is constantly interfering with the quality of program others are receiving.
I have read and understand these behavioral expectations and agree to abide by them during the event.
Attendee Signature: Date:
I have read and understand these behavioral expectations. Furthermore, I have discussed these
expectations with my child and she agrees to abide by them during her attendance at the event.
Parent/Guardian Signature:
Date:
