In the Holiday A - GSWNY.org

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In the Holiday A - GSWNY.org
GREAT
             THE

             ESCAPE
             2018
Winter
A

Holiday
    in the

  Woods
In the Holiday A - GSWNY.org
THE   GREAT ESCAPE 2018                        A   Winter Holiday in the Woods

 Welcome                                       It’s time, once again, to register for the Great Escape
                                               Weekend, October 5th-7th! Take this opportunity to enjoy
                                               a fun, relaxing, and educational weekend full of crafts,
                                               trainings, and outdoor activities.
           SWAPS and BINGO will begin the weekend on Friday night. There are usually around 150
           people attending.
           SILENT AUCTION: ALL silent auction items need to be grouped into a “theme” basket or
           box before you bring it. REMEMBER NO ALCOHOL (even unopened) ON SCOUT PROPERTY. All
           proceeds from this auction will benefit our different GSWNY camp properties. This year, we
           will have a silent plant auction on the dining hall porch. In addition, we will be raffling off a
           70"x80" quilt. Tickets will be sold separately from the auction (1 for $1, 6 for $5, or 15 for $10.
           HOSPITALITY: If desired, you may bring 1 SMALL item to share at the Hospitality table.
           Avoid things that need refrigeration. All left over snacks will be sold on Sunday morning and
           added to the auction proceeds.
           HEALTH HAVEN & OLD HEALTH HAVEN are available only to those with health needs - 1st
           come, 1st served.
           PARKING: We are a very large group and some may have mobility issues, but our main
           concern is safety! Please see the attached letter for our parking plan and accommodations for
           those with a valid, government issued handicap permit. Your cooperation in this request is
           truly appreciated for the safety of everyone.
                     MAIL registration forms to (to be received no later than July 21st):
                     The Great Escape Committee
                     C/o Karen Brown
                     PO Box 265
                     Holland, NY 14080
           Confirmation Letters: You will be receiving an e-mail upon receipt of your registration.
           Confirmation letters, including campsite, will be sent via e-mail beginning in September.
           The e-mail address is gswnyge@gmail.com. Please add this to your safe sender list so the
           e-mail will not be blocked.
           Placement into units and workshops is based on date received – get your registration in as
           soon as you know your plans. SORRY, NO LATE REGISTRATIONS WILL BE ACCEPTED.
           They will be returned as the PO BOX will be closed.
           Packing list is on the next page.

                                            See you at the weekend
                                               - The Great Escape Committee
In the Holiday A - GSWNY.org
THE   GREAT ESCAPE 2018             A   Winter Holiday in the Woods

  Packing List
            ‰‰ SWAPS for Fri. night (optional)
            ‰‰ $$ & change for pop/water (50¢) & auctions
            ‰‰ Check/credit card for LLGreen
                                                            Seasons Greetings,
            ‰‰ Layers of clothing
            ‰‰ Sturdy walking shoes
            ‰‰ Raingear/warm jacket
            ‰‰ Sleeping bag/bedroll and pillow
            ‰‰ Pajamas/underwear
            ‰‰ Socks
            ‰‰ Towel/Toiletries (unscented if in tents)
            ‰‰ Sit-upon/folding chair/stadium chair
            ‰‰ Insulated mug/water bottle (label)
            ‰‰ Flashlight/new batteries
            ‰‰ Supplies for workshops
            ‰‰ All medications including OTC (we cannot supply ANY)
THE   GREAT ESCAPE 2018                       A    Winter Holiday in the Woods

 Hello,                        2018 Campers
          We have just a few items that we want to touch base with our campers, before you come
          out to camp.
          Over the last few years we have noticed an increase of vehicles driving through the camp, I
          know we have an aging population and we certainly do not wish to single anyone out, BUT
          we have been asked by the Camp Facilities Director to solve this major issue. Not only is it
          a hazard for those who are walking from place to place but our camp roads are not meant
          for heavy traffic.
          The Great Escape Committee will provide a part-time, limited capacity shuttle van
          making the trip around camp at regular intervals. This will be available for those who
          have a handicap pass, handicap license plate, if you are elderly, recently injured
          or disabled and can’t walk around camp. Please mark the registration form if you fall
          into this category, then on Friday night, after picking up your registration information,
          you need to come and see me, Karen Baker, to get signed up with our drivers. You will be
          allowed to go park on the road closest to your unit to unpack only, but you will then have
          to park in the lower main parking lot for the whole weekend. You will NOT be allowed
          to drive around camp. The shuttle van and a few of the committee’s cars will be the only
          vehicles driving on camp property. There will be harsh consequences for disregarding
          this rule. This program worked well last year and we thank you for your ongoing support.
          You will receive (1) warning and if caught a second time, your registration will
          not be accepted for the subsequent year.
          If you have difficulty getting around, we highly encourage you to sign up for Health Haven
          so you are close to the dining hall. We will be filling Health Haven first with those who have
          requested it for mobility and health issues, you must make it clear on the registration form.

                                                             Thank you in advance
                                                             for your cooperation,
       WINTER TIME
                                                                    - Karen Baker
                                                                       Great Escape Chairperson
THE   GREAT ESCAPE 2018                                A     Winter Holiday in the Woods

      Saturday
                                                     Early Morning Historical Hike:
                                                     Wake yourself up with a vigorous       Supplies: Sturdy boots.
                                                     hike around 7 Hills as you learn       Instructor: Tammy Dziuba.
                                                     the history of this camp.              Fee: None.
                                                                                            Limit: None.
      SESSION 1 WORKSHOPS

 Archery Fun                                Let It Snow, Man!                          Positive Thinking
 Come join other leaders as you have        Ornament                                   Marbled Painting
 a chance to become Robin Hood.             Join other leaders in making a Let         Participants will be feeling pretty
 You’ve seen your girls try it; now it is   It Snow, Man! ornament from fabric         good about themselves after
 your turn to shoot a bullseye.             strips and scraps. Quick, fun, and oh      completing this easy project.
 Supplies: Shoes you aren’t afraid to       so cute!                                   Choose positive words that
 get wet or dirty.                          Supplies: Ruler, pencil, scissors          describe you and use them to
 Instructor: Hanna Schwartz.                (or rotary cutter).                        create a framed work of art!
 Fee: $5.                                   Instructor: Penny Marble.                  Supplies: A pair of scissors.
 Limit: 25 (you will be split into 2        Fee: $15.                                  Instructor: Amy Miehl.
 groups of 12 during this session for       Limit: none.                               Fee: $2.
 half the time each).                                                                  Limit: 15.
                                            Mosaic Coasters
 Canoe Fun                                  Learn how to make a tiled coaster          Songs and Ceremonies
 Come join other adult scouts as you        you can easily do with your troop.         Learn new songs to teach your girls.
 review basics of canoeing and then         Great for recycling material from your     Master different ceremonies to be
 put your skills to the test with some      house for a troop craft!                   used both indoors and outdoors. This
 competitive and fun games.                 Supplies: 2-4 matching salsa or            training includes a proper outdoor
 Supplies: Sturdy shoes                     spaghetti jar lids and a sponge. Tiles     flag ceremony.
 Instructor: Cindy Breeze.                  will be provided but you are more          Supplies: Pencil and paper (optional).
 Fee: $5.                                   than welcome to bring your own.            Instructor: Council Trainer.
 Limit: none.                               Instructor: Skylar Zuckerman.              Fee: none.
                                            Fee: $4.                                   Limit: none.
 Glitter Candle Holder                      Limit: 20.
 Make your own glitter candle holders                                                  Try Bunco
 to decorate your home on a cold            No-Sew Snowman                             Join other scouts in a fun game of
 winter day. Bring 1-3 glass jars,                                                     Bunco. Not sure how to play? We will
 rinsed and label removed.                  Wall Hanging
                                            Create a wall hanging you can              teach you. We promise you won’t be
 Supplies: Modpodge, Epson salt,                                                       disappointed.
 glass jars.                                display all winter. The 7” x 11” project
                                            is made from fabric, using a NO-SEW        Supplies: 4 quarters.
 Instructor: Alexandra Kuhns.                                                          Instructor: Doreen Grobe.
 Fee: $2.                                   technique. Ideal project for Cadette to
                                            Ambassador level girls.                    Fee: $1.
 Limit: 12.                                                                            Limit: 20.
                                            Supplies: pencil, sharp
                                            fabric scissors, Ultrafine
                                            Sharpie or pigma pen
                                            Instructors: Kathy Schell
                                            and Sandy Bitterman.
                                            Fee: $7.
                                            Limit: 16.
THE   GREAT ESCAPE 2018                               A    Winter Holiday in the Woods

                                                                         Can't wait
                                                                        to see you

      Saturday                                                           at camp!
                                                                           Best wish
                                                                                    es,
                                                                                           HAPPY HO

                                                                                          TO: CO-L

                                                                                          123 TIMBE
                                                                                                      LIDAYS!

                                                                                                  EADER SA

                                                                                                     RCREST RO
                                                                                                                LLY

                                                                                                                  AD

                                                                               Libby      RANDOLPH
                                                                                                      , NY

      SESSION 2 WORKSHOPS

 Engineering and Computer Left, Right, Center                                       Painted Wine Bottles
 Sciences for Older Scouts Bring six pennies as “chips” for a                       Come and learn how to paint on
 Learn all about the new badges and        rousing game of Left Right Center.       wine bottles. You will make both an
 journeys available to older scouts in     This quick-moving party game takes       adorable scarecrow bottle and a cute
 the field of engineering and computer     no skill and allows for conversation.    little snowman bottle.
 sciences. Have all your questions         Come enjoy, winner takes home            Supplies: 2 wine bottles.
 answered by the experts.                  the game.                                Instructors: Michelle George.
 Supplies: Pencil and paper.               Supplies: 6 pennies.                     Fee: $4.
 Instructors: Council Trainer.             Instructor: Doreen Grobe.                Limit: 14.
 Fee: none.                                Fee: $1.
 Limit: none.                              Limit: none.                             Pub Grub
                                                                                    Try your hand at making and eating
 Glass Ornaments                           Massage I                                some traditional pub food. Start off
 Come learn how to make a unique           Are you stressed? Enjoy a 20- or         with a hot bowl of cockaleekie soup
 hanging glass ball ornament. Each         30-minute chair or table massage         with a side of minced meat pasties.
 person’s will be different.               and truly relax for the day.             Top it off with a bit of triffle and
 Supplies: none.                           Instructors: Jesse and Zoe McCabe.       a spot of tea.
 Instructor: Maureen Daley.                Fee: $25 for 20 minutes,                 Supplies: Mess kit, camp chair
 Fee: $1.                                  $35 for 30 minutes.                      (optional).
 Limit: 15.                                Limit: 6-8 per session.                  Instructors: Cathy Liberante.
                                                                                    Fee: $2.
 Holiday Fun                                                                        Limit: 15.
 Join your friends to make a               Outdoor Cooking
 Christmas ornament out of recycled        Learn new cooking ideas using a          Rock Painting
 cards. This ornament can be done          dutch oven, grill, grill over a fire,    Learn all about the new craze of
 with Juniors and above. There will        tinfoil and a camp stove. Also, learn    rock painting. Paint a few rocks of
 also be time for everyone to test their   the correct safety procedures for food   your own and take this fun activity
 knowledge while you play several          storage, lighting a propane stove and    back to your girls.
 holiday trivia games.                     removing food from the fire. And don’t   Supplies: a variety of “flatter” rocks
 Supplies: 15-20 old Christmas cards       forget about the coffee…                 to paint (instructor will bring a limited
 and/or photocards, scissors, small        Supplies: Mess kit, 1 pot holder/oven    number), acrylic paints, paint brush,
 bottle of glue.                           mitt, camp chair (optional).             clear sealer or Mod Podge (if keeping
 Instructors: Eileen Kramer.               Instructors: Karen Baker.                rocks indoors).
 Fee: none.                                Fee: $2.                                 Instructor: Chris Pasek.
 Limit: 7.                                 Limit: 12.                               Fee: none.
                                                                                    Limit: 16.
THE   GREAT ESCAPE 2018                               A     Winter Holiday in the Woods

      Saturday
      SESSION 3 WORKSHOPS

 Adult Coloring                            Introduction to                            Quilted No-Sew Snowflake
 Join other adult scouts for some          Essential Oils                             Ornament
 relaxing time coloring and socializing.   Do you want to learn how to use            Create a beautiful ornament for your
 Supplies: Sharp colored pencils.          essential oils to provide support for      tree or for a gift. No sewing required.
 Instructor: Janice Morrissette.           your body and kick toxic chemicals         Supplies: Straight pins (beading-Dritz
 Fee: None.                                out of your home? Sample some              Size 14- 7/8”), thimble, scissors, pen,
 Limit: None.                              Vitality Oil-infused water while           ruler.
                                           learning some tactics that anyone          Instructor: Carol Woolson.
 Basket Weaving                            can do with essential oils. We’ll learn    Fee: $7.
 (double session)                          about oils and then make several           Limit: 12.
 Make a 4-space sectional basket.          easy projects such as foaming
 This basket is on a 6" base and is        hand soap and shower melts that            Service Unit Campout
 about 4” tall. It comes complete with     will replace some chemical-laden           (SUCO) Training Renewal
 small wooden handles (7” tall with        products from your home this holiday.      Join us for a chance to renew your
 handles on it).                           Please Note: We will be using              SUCO training. What better place to
 Supplies: all supplies provided.          100% Pure Therapeutic-Grade                renew than at camp itself!
 Instructor: Maureen Quale.                Essential Oils.                            Supplies: Pen and paper, if desired.
 Fee: $27 (includes embellishment).        Supplies: 1- or 2-qt glass or stainless-   Instructor: Cathy Liberante.
 Limit: 12.                                steel bowl, a stainless-steel spoon for    Fee: none.
                                           mixing, measuring cup, measuring           Limit: none.
 Denim Book Bag                            spoons, and a Sytrofoam egg carton.
 Learn how to make a cute bag out of       Bring a box big enough to hold the         Zentangle Santa Bag
 jeans. The perfect craft for yourself,    egg carton and a few small bottles to
 your family, or your troop.               take home.                                 (double session)
 Supplies: Old pair of jeans (any size     Instructor: Sue Ray.                       Bring a friend or come by yourself
 but not shorts), few skeins of any        Fee: $12.                                  but bring your creativity. You will
 color embroidery floss, needle, and       Limit: 24.                                 learn how to turn a plain canvas bag
 pins. Buttons optional.                                                              into an amazing bag
 Instructor: Kathy Weiss.                  Massage II                                 for the winter.
 Fee: none.                                Are you stressed? Enjoy a 20- or           Supplies: None.
 Limit: none.                              30-minute chair or table massage           Instructor: Joanne Ziolo.
                                           and truly relax for the day.               Fee: $8.
                                           Instructors: Jesse and Zoe McCabe.         Limit: 8.
                                           Fee: $25 for 20 minutes,
                                           $35 for 30 minutes.
                                           Limit: 6-9 per session.
THE   GREAT ESCAPE 2018                              A    Winter Holiday in the Woods

      Saturday
      SESSION 4 WORKSHOPS

 Afternoon Hike                           Massage III                               Robotics for
 Join your fellow scouts on a hike        Are you stressed? Enjoy a 20- or          Younger Scouts
 around 7 Hills. Learn about the lost     30-minute chair or table massage          Learn all about the new badges and
 units of Goodyear as you navigate        and truly relax for the day.              journeys available to younger scouts
 the Orange Trail. This is the perfect    Instructors: Jesse and Zoe McCabe.        in the field of robotics. Have all your
 hike to take to prepare you for a hike   Fee: $25 for 20 minutes,                  questions answered by the experts.
 with your troop.                         $35 for 30 minutes.                       Supplies: Pencil and paper (optional).
 Supplies: Hiking boots (trail gets       Limit: 6-9 per session.                   Instructors: Council Trainer.
 muddy), water bottle.                                                              Fee: none.
 Instructor: Antoinette Rozek.            Quilled Snowflake                         Limit: none.
 Fee: none.                               Learn the art of quilling with paper to
 Limit: none.                             make a delicate snowflake ornament        Ticket to Ride
                                          perfect for gift giving or to place on    Learn how to play the game
 Christmas Gifts for Troops               your own holiday tree. Everything you     Ticket to Ride. This is a great
 You will make 4 gift items that scouts   need to complete a snowflake will be      game to play with your troop at
 could make for Christmas gifts or        provided, so all you need is nimble       meetings or evenings during a
 other holidays. You will also be given   fingers. A protective box to keep it      camping trip. Easy to learn but will
 instructions and shown samples           safe is included in the fee.              provide hours of entertainment for
 of other gifts to make. We will also     Supplies: none.                           almost all age levels.
 talk about how to run a “GS Elves        Instructor: Jackie Cornwall.              Supplies: None.
 Workshop” for your SU, if anyone is      Fee: $2.                                  Instructors: Dora Maul and
 interested.                              Limit: 12.                                Rebecca Priest.
 Supplies: A shopping bag or                                                        Fee: none.
 recyclable tote to take your gifts                                                 Limit: 15.
 home in.
 Cost: $3.
 Limit: 8.
 Instructor: Rebecca Mattison                                                             We ha
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THE   GREAT ESCAPE 2018                               A      Winter Holiday in the Woods

 SaturdayWorkshops
Indicate your first (1), second (2), AND third (3) choices for EACH time period in the appropriate boxes. Workshop
sizes are LIMITED. Register early to receive your first choice. Pay for ONLY first choice workshop fees with your
registration. If necessary, refunds will be issued for closed or canceled workshops and additional fees for second or third
choices will be collected at camp.

       6:45-7:45am            9:00-10:30am           10:45am-12:00pm                1:45-3:15pm                 3:30-5:00pm

         Early Morning                                        Engineering and               Adult                    Afternoon
                                  Archery Fun                Computer Sciences
         Historical Hike
                                      Fee: $5                 for Older Scouts             Coloring                     Hike
           Fee: none                                            Fee: none                  Fee: none                  Fee: none

                                                                 Glass                                Basket Weaving
                                   Canoe Fun
  All workshop
                                      Fee:$5                   Ornament                               Double Session
  timeslots are as                                               Fee: $1                                  Fee: $27
  indicated.
                                                                                                                     Christmas
  Puzzles and cards               Glitter Candle                                         Demin Book
  are available for                                          Holiday Fun                                              Gifts for
                                      Holder                    Fee: none                   Bag
  your enjoyment all                  Fee: $2                                              Fee: none                  Troops
  weekend long.                                                                                                        Fee: $3

  REST AND                            Let It                                             Introduction                Massage III
  RELAXATION:                                                 Left, Right,
                                   Snow, Man!                                            to Essential                    Fee:
  Take some time                                                Center
  for yourself by the               Ornament                     Fee: $1                      Oils          check    $25 - 20 min.
                                     Fee: $15                                              Fee: $12           one    $35 - 30 min.
  lake or one of the
  many other areas
  of camp.                           Mosaic                    Massage I                  Massage II                  Quilled
                                                                   Fee:                       Fee:
                                    Coasters                                                                         Snowflake
                                                     check     $25 - 20 min.     check    $25 - 20 min.
                                      Fee: $4          one                         one                                 Fee: $2
                                                               $35 - 30 min.              $35 - 30 min.
  NAME
                                    No-Sew                     Outdoor                     Quilted                     Robotics
                                   Snowman                     Cooking I                  Snowflake                  for Younger
                                  Wall Hanging                (until 1:30pm)              Ornament                      Scouts
                                      Fee: $7                    Fee: $2                    Fee: $7                   Fee: none

                                      Positive
                                  Thinking Marbled
                                                             Painted Wine                SUCO Renewal                 Ticket to
                                      Painting                  Bottles                    Training                     Ride
                                                                 Fee: $4                   Fee: none                  Fee: none
                                      Fee: $2
          Amount
      enclosed for                 Songs and                                                     Zentangle Santa Bag
                                                               Pub Grub
        1st-choice
                                   Ceremonies                 (until 1:30pm)                       Double Session
       workshops                     Fee: none                   Fee: $2                                  Fee: $8

                                                                 Rock
                                    Try Bunco
                                      Fee: $1                   Painting
                                                                Fee: none
THE   GREAT ESCAPE 2018                               A    Winter Holiday in the Woods

      Registration
                                                                              October 5-7, 2018
                                                                              CAMP SEVEN HILLS GOODYEAR
                                                                              10150 Olean Road (Rt. 16)
                                                                              Holland, NY 14080

PLEASE                 Name
 PRINT                 Phone
NEATLY
             Street Address
                          City                                             State                Zip
             E-Mail Address
           Your confirmation will be sent to this address. Confirmations will be emailed starting in SEPTEMBER.

      Yes, I am willing to be a First Aider for my unit. [exp date: CPR _________ First aid_________]
      Yes, I am willing to be the Unit Leader (must be in unit Friday when campers arrive and Sunday when they depart).

 UNIT/HOUSING PREFERENCE: Highland has platform tents and Plainsman has cabins. Brownie
 Lodge and Bunkhouse are both lodges and are also available. You may also bring your own tent. Health
 Haven and Old Health Haven are available only to those with medical needs. Accommodations are
 on a first-come, first-served basis.
 	        I would prefer to sleep in ____________________________________ unit.
 	 I need a backboard.
  Available on a first-come, first-served basis as numbers are limited.
  Not available in Highland or Brownie Lodge Overflow Tents.
          I will be bringing my own tent and sleeping in Tent City.
          I would like to bring my own trailer. (No hookups available, no longer than 20’ in length)

 SPECIAL NEEDS: Please indicate any special FOOD and/or ENVIRONMENTAL requirements for the
 weekend. If you are a vegetarian, note it here. We will do our best to accommodate you.
 __________________________________________________________________________________
      I will need shuttle service and have a valid, government-issued handicap parking permit.

                                                                             CONTINUES ON NEXT PAGE
THE   GREAT ESCAPE 2018                         A    Winter Holiday in the Woods

       Registration
                                                                    October 5-7, 2018
                                                                    CAMP SEVEN HILLS GOODYEAR
                                                                    10150 Olean Road (Rt. 16)
                                                                    Holland, NY 14080

      FRIDAY, SATURDAY,             FRIDAY AND                SATURDAY                   SATURDAY
        AND SUNDAY                   SATURDAY                AND SUNDAY                    ONLY
         Full weekend:             Friday through            Saturday lunch                Saturday
             $47.00                Saturday lunch:       through Sunday brunch:          (lunch only):
                                       $28.00                    $39.00                     $20.00
         Friday through
        Sunday morning         Friday through Saturday                                     Saturday
          (no brunch):              evening dinner:                                   (lunch and dinner):
             $44.00                     $41.00                                              $33.00

                                         Amount of registration choice above:		 $ __________________

       WORKSHOP FEES (Include workshop sheet – payable with registration)         + $ __________________

  T-SHIRT ORDER (Include order form next page - payable with registration)        + $ __________________

       PLEASE                                                         = TOTAL 		 $ __________________
        PRINT
       NEATLY
                      Check or Money Order in U.S. funds made payable to:
                                 Great Escape Committee
                      UNLESS FULL PAYMENT IS INCLUDED YOU WILL NOT BE REGISTERED!

                      Please complete this form, the workshop registration, your adult health form, and the
                      clothing order form and mail with your check or money order by July 21, 2018 to:
       Do not mail
      to Girl Scout   The Great Escape Weekend Committee
         council.     c/o Karen Brown, P.O. Box 265
                      Holland, NY 14080
                                   ALL FEES ARE NON-REFUNDABLE.
             ONLY ONE PERSON PER APPLICATION. PLEASE MAKE COPIES FOR ADDITIONAL PEOPLE.
THE   GREAT ESCAPE 2018                              A             Winter Holiday in the Woods

                                                                                                                PLEASE

        T-Shirt Order Form                                                                                       PRINT
                                                                                                                NEATLY

      T-shirts and Long sleeve shirts, are a universal cut, 50/50 blend                     Special Item: This year we will
      shirt. The t-shirt is a sandstone color. The design on the front of the               be offering a universal cut, 50/50
      shirt is the picture below. Do not be disappointed at camp. There                     blend full zip hoodie with the
      will be no extras!                                                                    Great Escape Peace Sign logo on
                                                                                            it. The hoodie will be cardinal red
      Name                                                                                  with the design in white. Order now
                                                                                            and there will be no extra at camp.
      Phone
                                                                                            HOODIE DESIGN:
      SHORT-SLEEVE T-SHIRTS
           Small ($11) Qty: ______
        Medium ($11) Qty: ______
                                            SHIRT DESIGN:
           Large ($11) Qty: ______
        X-Large ($11) Qty: ______
              2X ($13) Qty: ______
                                                                                            HOODIE
                                                         MARTINLUTHERKING

              3X ($15) Qty: ______
                                                                                                 Small ($22) Qty: ______
              4X ($16) Qty: ______
                                                                                              Medium ($22) Qty: ______
              5X ($17) Qty: ______
                                                                                                 Large ($22) Qty: ______
      LONG-SLEEVE T- SHIRTS                                                                   X-Large ($22) Qty: ______
           Small ($14) Qty: ______                                                                  2X ($26) Qty: ______
        Medium ($14) Qty: ______                                                                    3X ($26) Qty: ______
           Large ($14) Qty: ______                                                                  4X ($27) Qty: ______
        X-Large ($14) Qty: ______                                                                   5X ($28) Qty: ______
              2X ($16) Qty: ______
              3X ($16) Qty: ______                     Shirt Total Enclosed $_____________
                                                                            Fill in total on the weekend registration section
                                                                                                 (previous page) of form also.
THE   GREAT ESCAPE 2018                                                   A     Winter Holiday in the Woods

                                                                                    GIRL SCOUTS OF WESTERN NEW YORK, INC.
                                                                                                  ADULT HEALTH STATEMENT
                                                                                              PLEASE FILL OUT THIS FORM COMPLETELY
                                                                                               AND RETURN WITH YOUR REGISTRATION

      Last Name:                                                      First Name:                                       MI:

      Address:                                                        City:                                   State:    Zip:

      Phone (home):                                   Phone (cell):                                  Email:

      IN CASE OF EMERGENCY NOTIFY:                                            IF CANNOT BE REACHED, NOTIFY:
      Name:                                                                   Name:

      Phone Number (s):                                                       Phone Number (s):

      Address:                                                                Address:

      Relationship:                                                           Relationship:

      HEALTH INSURANCE
      Type of Insurance:                                                      Insurance #:

      Does your insurance require a pre-approval phone call?      ⃞ Yes   ⃞ No

      Doctor’s Name:                                                          Doctor’s Phone Number:

      CONFIDENTIAL HEALTH HISTORY
                                                            If yes, please explain your condition further:
      Do you have any allergies?           ⃞ Yes   ⃞ No

      Do you have asthma?                  ⃞ Yes   ⃞ No

      Do you have high blood pressure? ⃞ Yes       ⃞ No

      Are you a diabetic?                  ⃞ Yes   ⃞ No     If yes, do you take insulin?

      Are you on a special diet?           ⃞ Yes   ⃞ No

      Date of most recent tetanus shot:    ⃞ Yes   ⃞ No
      Comments on any other health factors to which we should be alerted?

      MEDICATION:
      Are you on any medication?                   ⃞ Yes   ⃞ No
      State medication(s) and dosage(s):

      This health statement is complete and true to the best of my knowledge. I also understand that this information will be
      shared on a need-to-know basis with appropriate medical personnel. I hereby give permission for the adult in charge to
      secure the services of a licensed physician, if necessary and to give proper treatment for any injury or illness that is
      deemed necessary.

      Signature: ____________________________________________________________ Date:______________________

       (#350-AD-HLT)
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