2023 PIPERWOOD & WINDY MEADOWS DAY CAMP APPLICATION

Register for camp online! Visit us at www.gswny.org

How did you hear about our Summer Day Camp Programs?

Or mail this application and payment to: Rochester Service Center
1000 Elmwood Avenue, Door 9
Rochester, NY 14620
Fax: 585.292.1086

CAMPER INFORMATION
Camper’s Name
Date of Birth	Current Age
Address	County
City/State/Zip Home Phone:
Family E-mail
Buddy Name (only applicable if buddy is in the same age group and same program):

CAMPER MEMBERSHIP INFORMATION

SCHOOL INFORMATION
Grade in school (9/2023):
Name of School:

CAMP INFORMATION PACKET (ALL CAMPERS)
Packets contain camp information that parents are required to review, directions to your camp, packing lists for your camper and so much more. You will receive emails indicating receipt of registration, balance owed if applicable and a link to your Camp Information Packet.
T-SHIRT SIZE:
•	Youth S ¨Youth M ¨ Youth L ¨ Adult S
•	
Is the camper a registered Girl Scout? �Yes �No If no, please enclose a $25 membership fee on a separate check/Money Order.
PARENT/GUARDIAN INFORMATION
•	
Adult M ¨ Adult L ¨ Adult XL

FORM OF PAYMENT

Parent/Guardian #1
Relationship to Camper
Email

Cell

Parent/Guardian #2
Relationship to Camper
Email

Cell

Payment must include at least the
$25 deposit AND the Girl Scout Membership fee (if applicable)
Total amount of payment: $
❑	My payment includes the $25 Girl Scout membership fee
❑	

If different from camper’s:
Address Phone (Home)

If different from camper’s:
Address Phone (Home)

Camper lives with: � Both parents � Mother � Father � Other:
CAMPER PROGRAMS/SESSIONS CHOICES AT DAY CAMP
Please print neatly the Program Name; Bus Stop requested; Name and place an “X” in the boxes for the other items which you are requesting.
Girls should pick programs based on grade level they will be entering in the NEXT school year (2023).

15
❑	
Cash, Check, or Money Order
-OR-
❑	
Camp Choice:
Piperwood (P) or
Windy Meadows (WM)	Session Date(s)
-or- Session Number	
Program Name	
Bus Stop Requested	Bus Stop
$50	
Overnight
$15/$10 	Before
& After Care
$30/$0	Before Care ONLY
$15/$0	After Care ONLY
$15/$0	Financial Aid Request	

										

										

MC � Visa � Discover �AMEX Credit Card Account #:

Exp. Date:

Print Name of Cardholder: Signature of Cardholder:

PARENT/GUARDIAN AGREEMENT (ALL CAMPERS)
GSWNY Member and Camp Regulations: I hereby register my child for designated session(s) at one of the GSWNY summer camp(s) and I authorize my daughter to become a member of Girl Scouts of Western New York. My daughter and I have read and understand the information in the camp brochure and agree to cooperate with all camp regulations.
Camp Information Packet: I will read the Camp Information Packet upon registration and understand I am responsible for following the camp policies including but not limited to payment procedures and deadlines, parent/camper behavior agreement, internet policies and camp hours of operation.
Participation Permissions: I give full permission for my daughter to attend and participate in all camp activities, including out-of-camp trips/hikes. I give consent for my child to take part in field trips or excursions off camp property under proper supervision.
Photographs: I give consent that GSWNY may use photographs, slides, and video of my child, as may be needed for its records or promotional purposes including website material to promote the interest of Girl Scouting. This includes the American Camp Association, the United Way grants, and Camp America.
Deadlines and Forfeiture of Registration: I further understand that my child’s spot is reserved only upon receipt by GSWNY of the fully completed registration form health information and the $25 per child registration fee and that failure to pay balance due by the deadline, will forfeit my child’s registration.
Inherent Risk Statement: I understand that GSWNY has taken the necessary steps to provide the appropriate training, the necessary equipment and skilled seasonal staff for my child’s camp experience. I also acknowledge that there are inherent risks associated with camp activities such as ropes challenge course, horseback riding, rock climbing, whitewater rafting, swimming, and boating/canoeing/kayaking and other components of camp and I am aware that by participating in any of these activities that my child could be injured.
As the parent/guardian accountable for my child, I assume and accept the full responsibility for her participation at camp. I am also aware of and assume the risks associated with camp and agree to release and hold harmless Girl Scouts of WNY, Inc., its employees (full, part-time and seasonal), agents and volunteers from any and all claims or liabilities of any kind arising out of my child’s participation at any of the GSWNY camps.
PARENT/GUARDIAN SIGNATURE:	DATE:

FINANCIAL AID
GSWNY has summer camp financial aid available for our girls. Please
fill out both pages 1 and 2 of this Registration Form completely, along with the income verification form (located in the camp catalog) and submit as early as possible so that we can offer your girl the most financial assistance available to her.
PLEASE FILL THIS SECTION
OUT COMPLETELY IF ASKING FOR FINANCIAL AID.

FAMILY CONTRIBUTION:
How much can your family contribute (in addition to the deposit) towards camp? $

FINANCIAL AID STATEMENT OF NEED
(attach a separate sheet of paper if necessary) On the lines below, please explain why you are requesting financial assistance. Please be specific

HOUSEHOLD INCOME INFORMATION
Annual Household Combined Income: $
# of adults supported by income: # of children supported by income:
Parent/Guardian 1 Name:
�Employed �Unemployed �None/Retired
�One or more adults are working full-time
Parent/Guardian 2 Name:
�Employed �Unemployed �None/Retired
�One or more adults are working full-time

about your present financial obligations. Your
application cannot be processed without this information. All information included on this form is held strictly confidential.