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Program Kit Reservation Form
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PERSONAL INFORMATION
Name of Adult completing this form
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zipcode
*
Your answer
E-mail Address
*
Your answer
Phone Number
*
Your answer
Service Unit
Your answer
Troop Number
Your answer
PROGRAM KIT INFORMATION
Who is the audience you are using this kit for?
*
Girl Scout troop, Partner Organization, Recruitment, or Other
Your answer
Which Program kit are you reserving?
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Choose
Anti-Bullying (Daisies and Brownies)
Anti-Bullying(Juniors)
Cyber Bullying and Social Media Safety (Cadettes, Seniors, and Ambassadors)
Free Being Me-Healthy Self Esteem (Brownies and Juniors)
Free Being Me-Healthy Self Esteem (Cadettes)
Leadership (Daisies and Brownies)
Leadership (Juniors and Cadettes)
Leadership (Seniors and Ambassadors)
STEM (Daisies and Brownies)
STEM (Juniors and Cadettes)
Pick up date
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Please allow one week for confirmation
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/
DD
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YYYY
Return Date
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Must be ONE month after the pick up date.
MM
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DD
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YYYY
Pick up location
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Please note that program kits must be picked up from and returned to the same location.
Memphis Office
Jackson Office
Tupelo Office
Corinth Office
Required
Signatures
You agree your electronic signature are the legal equivalent of your manual signature on this application. By selecting the "Submit" button, you are signing this application electronically.
The non-refundable checkout fee for each program kit is $5.00. This fee is used to replenish materials.
*
Sign if you understand and agree.
Your answer
An additional fee of $25.00 will be attached to program kits not returned by the assigned deadline and/or that are damaged or destroyed.
*
Sign if you understand and agree.
Your answer
To ensure that girls get the best possible experience from using the Program Kits, please allow time to familiarize yourself with the contents of the program kit and the accompanying Activities Guide before beginning the activities.
*
Sign if you understand and agree.
Your answer
Submit
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