Program Guide Fall 2013 | Page 11

Girl Scouts—Dakota Horizons 1002 43rd St S, Fargo, ND 58103 701-293-7915 or 877-904-8168 Fax 701-293-7962 Attn: Program Registrar Event Registration Form Troop # ___ ___ ___ ___ ___ Registering (circle one) Individual Grade Level (circle one) Daisy (K-1) Cadette (6-8) Troop Group Program Aide Junior (4-5) Ambassador (11-12) Brownie (2-3) Senior (9-10) ADULT REGISTRATION CONTACT The adult listed below will receive confirmation, any updated information and is responsible for relaying this information to those registered. Name____________________________________________ E-mail Address ___________________________ Address__________________________________________ Home Phone______________________________ City______________________ State______ Zip _________Work _____________Cell___________________ EMERGENCY CONTACT Name____________________________________________ Home Phone______________________________ Work Phone ______________________________________ Cell Phone________________________________ EVENT INFORMATION - Please list names of Girls and Adults registering on back. Event Name_____________________________________ Event Date________________________________ Event Location___________________________________ Event Code_______________________________ Mail registration form and payment to: Girl Scouts – Dakota Horizons, 1002 43rd St S, Fargo, ND 58103. Or, fax with credit card payment information to 701-293-7962. Registration and payment must be received into Program Registrar office in Fargo, ND by event registration deadline. # Event Fee Girl(s) ____X $ ________ = Non-Member Girl(s) ____X $ ____+ $20 = Adult(s) ____X $_________ = Subtotal Subtract Attached Dakota Certificates Subtract Requested Financial Assistance Amount Due Total Enclosed Outstanding Balance $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ Method of Payment – one payment or check per registration form. Troop Check # __________________________ Personal Check # ________________________ Money Order # __________________________ Credit Card Payment - Circle One Visa Master Card Discover For Credit Card payment complete information below. Credit Card Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiration Date ________________ 3 Digit Security Code ___ ___ ___ Name as shown on card _____________________________________ Amount to Charge $____________Signature __________________________________ Date _____________ PLEASE TURN OVER AND COMPLETE OTHER SIDE. DUPLICATE FORM AS NEEDED. Revised 8/28/2013