Extended Travel/High Risk Application For troop or groups planning Extended/International travel and/or High Risk Activities Trip Information arrowup6 Application Date * Type of Application * Preliminary (required for all travel overnights) Revised (as needed) Definition of Activity Types Extended Domestic Travel is greater than 4 nightsHigh Risk Activity as defined by Safety Activity CheckpointsSelect all activities that apply to this trip/event Type of Activities * Indoor Overnight Camping Extended Domestic Travel International Travel High Risk - with Overnight High Risk - No Overnight Select all activities that apply to this trip Describe High Risk Activity * Number of Nights * 1 - 3 nights 4 - 9 nights 10+ nights Activity/Travel Start Date * Activity/Travel End Date * Type of Lodging * Girl Scout Program Center or Property Campground Hotel/Motel/Hostel/Time Share/Other Rental Private Home Private Rental - Airbnb Private Rental - HomeAway Private Rental - Vrbo Cruise Ship Other (Explain below) Select all types of lodging that that apply to this trip/event. Other Type of Lodging * Examples of "Other" can be (Museum, Organized Camp, Tall Ship etc...) Location/Destination * Enter the Location and/or Destination Location Address * Enter the Street Address, City, State and Zip Code. Location Phone * Group Information arrowup6 Type of Group * Troop Group Service Unit Service Unit Name Alamitos/Marina Alhambra/Rosemead/Santa Fe Trails Anita Oaks/Mission Camellias Bellflower/Hollymount Belmont Bonita Burbank Campo Verde Canon Trails Canyon Star Center City Chino Chino Hills Claremont Compton/Lynwood Covina Oaks Coyote Canyon Crown Poppy Culver City CV/Glendale East LA El Segundo Gateway Glendora Golden Savannah Heart of the Valley Heritage Committee Highland Rose Holly Hills Kern King Harbor La Brea Heights La Canada Lachen Lakewood Lancaster Las Caballeras Las Virgenes Lawnthornes Magnolia Manhattan Beach Marina Mission Rose Monrovia/Duarte Mountain View North Redondo Beach North River Northeast Hills Ontario/Montclair Palisades/Malibu Palmdale/Acton/Agua Dulce Pomona Puente Hills PV/Penn Rancho Calabasas Rancho Foothills RDE/Sil-Dom River Trails Robotics Team Sagebrush San Marino San Pedro Santa Monica Bay South Bay Four South Pasadena South Torrance Southeast Stoneyridge Testing Only - Do Not Use Torrance Twin Oaks Upland West Covina Westchester/Del Rey Westside Woodland Hills Please select the Service Unit that the Group Leader is from Troop #, Service Unit #, or name, Group Name Please enter either your Troop Number if this is a troop event or your Specialty Group Name. Please don't enter your troop name if you have one. Girl Scout Level(s) * Brownie Junior Cadette Senior Ambassador Click all that apply. Is the Adult in Charge of Trip the Troop Leader * Yes No Adult in Charge of Trip * Enter the name of the adult in charge of the trip or overnight. Adult's Address * Include street, city, state and zip code Adult's Home Phone Number * Adult's Cell Phone Number * Adult's Email Address * Troop Leader's Name * Troop Leader's Phone Number * Troop Leader's Email * Overnight/Trip Details arrowup6 Girl Planning * How did the girls partipate in the planning of this trip? Preparation * What preparation have the girls had for this trip? What type of activities are planned? * Mode of Transportation * Car/Van Train Boat Airplane Bus Public Transportation Rental (car or van) Other Check all that apply to the trip. Review Safety Activity Checkpoints under the Transporting Girl Scouts section for requirements of each mode of transportation. Note: 15 passenger vans are not recommended. Further Explanation * Please explain "Other" Mode of Transportation Offsite Emergency Contact * Please enter name of person who can be contacted in an Emergency. Phone Number of Emergency Contact * if more than one, enter details in comments at bottom of form. Number of Girls Participating * Number of Adults Participating * Total Number of Participants I confirm that all adults have met Girl Scout Requirements to be on this Trip. * Yes No Confirmation that all adults have met the requirements stated in Safety Activity Checkpoints. All attending Adults chaperoning, driving, overseeing Girl Scouts and activities - are a registered member, completed an appropriated background screening, and completed all required position-relating training, including the Child Abuse and Neglect Prevention training. Consult Safety Activity Checkpoints for details. Additional Trip Insurance * Yes No Basic Plan 1 covers Girl Scout members and non-members, who are invited to participate. If your trip is international, then additional Insurance (Plan 3PI) is required. Adult Training Certifications/Qualifications arrowup6 First Aider Name * Phone Number of First Aider * Email Address of First Aider Type of Certification (check all that apply) * First Aid/CPR/AED Wilderness and Remote First Aid Healthcare Professional First Aid/CPR/AED Certification Expiration * Wilderness and Remote Certification Expiration * Professional Healthcare Title * Please enter professional title of the First Aider. Please make sure they are certified to handle emergency first aid. Indoor Overnight Trained Adult * Indoor Overnight Training Completion Date * Domestic Troop Travel Trained Adult * Domestic Troop Travel Training Completion Date * International Travel Trained Adult * International Travel Training Completion Date * Camping Skills Trained Adult * Camping Skills Training Completion Date * Will this trip include any water activities? Yes No Who will be overseeing the water activities? (Check all that apply) * Certified Lifeguard (provided by site) Certified Lifeguard (not provided by site) Certified Swim Watcher Certified Lifeguard Name (not provided by the site) * Lifeguard Certification Date * Certified Swim Watcher Name * Swim Watching Certification Date * Will this trip include any backpacking activities? * Yes No Backpacking Trained Adult * Backpacking Training Completion Date * Would you like to list any additional adults with specialty training? * Yes No Type of Training * Trained Adult * Training Completion Date * Documents Upload arrowup6 Roster of all Participants - Girl Scouts and Adults * Drop a file here or click to upload Choose File Maximum file size: 52.43MB File can be a .doc, .docx, .pdf, .xls, .xlsx, .jpg and .csv Please upload a of list names of all attending girls and adults with cell numbers. Please identify the drivers. According to GSGLA Adult Volunteer Practices and Procedures under Vehicle Drivers, Leaders can ask to see proof of valid license, current liability information and current vehicle registration for driver(s). Itinerary file upload * Drop a file here or click to upload Choose File Maximum file size: 52.43MB Upload a copy of the trip itinerary. File can be a .doc, .docx, .pdf, .xls, .xlsx, .jpg and .csv Detailed Trip Budget * Drop a file here or click to upload Choose File Maximum file size: 52.43MB File can be a .doc, .docx, .pdf, .xls, .xlsx, .jpg, and .csv. Expenses include: transportation, lodging, meals, program cost, insurance, emergency funds. Income includes: Product Program sales, troop/group dues, individual Girls/Adults, and extra money earning activities and sponsorships. Back Up Plan * What alternative plan does the troop/group have should this trip/activity not take place? Submission Name * Name of person submitting this application Submitter's Email * Contact information if problem with this application. Submitter Comments Agreement Statement * Yes By submitting this form, I agree that the above statements are true, that I have read and agree to adhere to the GSUSA and GSGLA policies regarding troop travel, overnight activities, high-risk activities, and safety as stated in Safety Activity Checkpoints. I have reviewed the policies concerning troop travel, overnights, and high-risk activities and agree to adhere to them. I have reviewed this form and understand my (our) responsibilities. Print application before submittal, in case the server goes down. If you are experiencing problems in getting your application submitted and you are using Internet Explorer as your browser please switch over to Chrome., Firefox or Safari. If you continue to have problems please try later in the day. Sometimes we have been experiencing problems with the server. These are temporary. You should receive a confirmation email in 5 to 10 minutes. Thank You Captcha If you are human, leave this field blank.
