Lock in forms
AHG Multi-Troop Lock-in 2014 Girl Registration Form Participant Name:____________________ Grade:_____ Level: Pioneer or Patriot
! Troop: _________ ! Home Address:
!
Troop Church:_________________________ ______________________ ______________________ ______________________
Parent email address: Home Phone: (___)-___-____ Cell Phone: (___)-___-____ Medications:
! Special Needs ! FOOD Allergies or sensitivities: ! Other Allergies:
Preferred Pick-up Time:
!
Fri. 10:30 PM Sat. Before Mass 8:30-8:50 AM Sat. After Mass: 9:45 AM
Registration Fee is $15. The fee is non-refundable once payment has been received. Checks should be made payable to Holy Trinity. Please write “AHG Lock-in” on the memo line so that payment can be recorded properly.
! Please send Registration Form, Permission slip and payment together to: ! Holy Trinity Catholic Church Attn: Francine Orr-AHG Lock-in 8213 Linton Hall Rd Gainesville, VA 20155
!
All forms and payment must be received by Wednesday, January 8, 2014.
Office Use: Date Received: _____
Payment Received: ______ Permission Slip Received: ______
American Heritage Girls, Inc.
175 Tri-County Parkway, Suite 100 Cincinnati, OH 45246 513-771-2025 (fax) 513-771-2595
Parent/Guardian Permission Slip
!
Please return this form to the leader by:1/8/2014 Troop #: 1975, 1947, 1148, 0312, 0683, 0633 is going to LOCK-IN on 1/17-1/18/2014 (date). Activities will include:Snack, earning the dance badge, lock-in sleepover, breakfast, Mass Place: Holy Trinity Catholic Church
Phone #: (703)753-6700
Address: 8213 Linton Hall Rd, Gainesville, VA 20155 Leaving from:self transportat (time):6:45pm Friday, Jan 17, 2014_ Returning to:self transport at (time): 9:45am Sat, Jan 18, 2014 (10:30pm Fri no sleep-over or 8:30 Saturday morning if not attending mass) Leaders/Adults accompanying girls: VA633: Francine Orr, Carrie Hall, Kate Downes ( and visiting troop leaders) Emergency Contact Person: Francine Orr (703)727-7499, Carrie Hall (540)270-5409, Kate Downes (571)214-3554 OFF SITE Emergency contact: Lisa Mark (321) 591-5429 Emergency Contact Phone #: see above Leader’s Signature:Francine Orr
------------------(Cut here and keep the above for your records)-----------------
!
(Please use BLUE INK when completing this form!)
My daughter, , has my permission to participate in (activity) on (date) . To the best of my knowledge, she is in good physical condition with no serious illness or operation since her last health exam.
YES
NO
If no, explain on back.
Is she currently taking any medications?
YES
NO Specify:
During this activity, I can be reached at: Phone #:
Address:
If I cannot be reached, please contact: Phone #: Relationship to girl: In the event that I cannot be reached in an EMERGENCY, I hereby give my permission to the physician selected by the person in charge to secure emergency treatment for my child as named above. Parent/Guardian Signature _____________________________________ Date _____________
AHG Multi-Troop Lock-in 2014 Adult Form Chaperone Name: ____________________
! VIRTUS Compliant: Yes or No ! AHG Registered Leader: Yes or No ! Troop: _________ Troop Church: _________________________ ! Home Address:
______________________ ______________________ ______________________
Email address: Home Phone: (___)-___-____ Cell Phone: (___)-___-____ Emergency contact name _________________________________ Emergency contact phone # _________________________________ FOOD Allergies or sensitivities:
!
Other Allergies: Please indicate if you are planning to leave before the end of the lock-in (i.e. before Mass)
!
**Please also keep in mind that the leaders from each troop are responsible for bringing their girls’ AHG medical forms.**
! Adults are complimentary. ! Please send Registration Form to: !
Holy Trinity Catholic Church Attn: Francine Orr-AHG Lock-in 8213 Linton Hall Rd Gainesville, VA 20155
!
Forms must be received by Wednesday, January 8, 2014.
Office Use: Date Received: _____
! Troop: _________ ! Home Address:
!
Troop Church:_________________________ ______________________ ______________________ ______________________
Parent email address: Home Phone: (___)-___-____ Cell Phone: (___)-___-____ Medications:
! Special Needs ! FOOD Allergies or sensitivities: ! Other Allergies:
Preferred Pick-up Time:
!
Fri. 10:30 PM Sat. Before Mass 8:30-8:50 AM Sat. After Mass: 9:45 AM
Registration Fee is $15. The fee is non-refundable once payment has been received. Checks should be made payable to Holy Trinity. Please write “AHG Lock-in” on the memo line so that payment can be recorded properly.
! Please send Registration Form, Permission slip and payment together to: ! Holy Trinity Catholic Church Attn: Francine Orr-AHG Lock-in 8213 Linton Hall Rd Gainesville, VA 20155
!
All forms and payment must be received by Wednesday, January 8, 2014.
Office Use: Date Received: _____
Payment Received: ______ Permission Slip Received: ______
American Heritage Girls, Inc.
175 Tri-County Parkway, Suite 100 Cincinnati, OH 45246 513-771-2025 (fax) 513-771-2595
Parent/Guardian Permission Slip
!
Please return this form to the leader by:1/8/2014 Troop #: 1975, 1947, 1148, 0312, 0683, 0633 is going to LOCK-IN on 1/17-1/18/2014 (date). Activities will include:Snack, earning the dance badge, lock-in sleepover, breakfast, Mass Place: Holy Trinity Catholic Church
Phone #: (703)753-6700
Address: 8213 Linton Hall Rd, Gainesville, VA 20155 Leaving from:self transportat (time):6:45pm Friday, Jan 17, 2014_ Returning to:self transport at (time): 9:45am Sat, Jan 18, 2014 (10:30pm Fri no sleep-over or 8:30 Saturday morning if not attending mass) Leaders/Adults accompanying girls: VA633: Francine Orr, Carrie Hall, Kate Downes ( and visiting troop leaders) Emergency Contact Person: Francine Orr (703)727-7499, Carrie Hall (540)270-5409, Kate Downes (571)214-3554 OFF SITE Emergency contact: Lisa Mark (321) 591-5429 Emergency Contact Phone #: see above Leader’s Signature:Francine Orr
------------------(Cut here and keep the above for your records)-----------------
!
(Please use BLUE INK when completing this form!)
My daughter, , has my permission to participate in (activity) on (date) . To the best of my knowledge, she is in good physical condition with no serious illness or operation since her last health exam.
YES
NO
If no, explain on back.
Is she currently taking any medications?
YES
NO Specify:
During this activity, I can be reached at: Phone #:
Address:
If I cannot be reached, please contact: Phone #: Relationship to girl: In the event that I cannot be reached in an EMERGENCY, I hereby give my permission to the physician selected by the person in charge to secure emergency treatment for my child as named above. Parent/Guardian Signature _____________________________________ Date _____________
AHG Multi-Troop Lock-in 2014 Adult Form Chaperone Name: ____________________
! VIRTUS Compliant: Yes or No ! AHG Registered Leader: Yes or No ! Troop: _________ Troop Church: _________________________ ! Home Address:
______________________ ______________________ ______________________
Email address: Home Phone: (___)-___-____ Cell Phone: (___)-___-____ Emergency contact name _________________________________ Emergency contact phone # _________________________________ FOOD Allergies or sensitivities:
!
Other Allergies: Please indicate if you are planning to leave before the end of the lock-in (i.e. before Mass)
!
**Please also keep in mind that the leaders from each troop are responsible for bringing their girls’ AHG medical forms.**
! Adults are complimentary. ! Please send Registration Form to: !
Holy Trinity Catholic Church Attn: Francine Orr-AHG Lock-in 8213 Linton Hall Rd Gainesville, VA 20155
!
Forms must be received by Wednesday, January 8, 2014.
Office Use: Date Received: _____
