This form is for your use to help you keep track
of due dates for your encampment.
ENCAMPMENT DATE: _______________
DUE DATE (CHECK WHEN DONE/SUBMITTED TO COUNCIL):
DUE ASAP:
 ENCAMPMENT DIRECTOR TRAINING- if needed.
 SU RESERVATION FORM including EQUIPMENT REQUEST.
 LEASED VEHICLE REPORT- if needed.
 WATERFRONT HOLD REQUESTED (If needed).
Please reserve the waterfront ASAP, to be sure it is held for you, and not reserved by
another group. The completed Waterfront Reservation Form & lifeguard certifications
may be sent 2-4 weeks prior to encampment dates.
4 MONTHS PRIOR:
 CHANGES TO FACILITIES RESERVED (if needed) - to receive 100% refund.
2 MONTHS PRIOR:
 CHANGES TO FACILITIES RESERVED (if needed) - to receive 75% refund.
 FINAL BALANCE PAYMENT DUE
1 MONTH PRIOR:
 CHANGES TO FACILITIES RESERVED (if needed) - to receive 50% refund.
(No refund less than 1 month prior)
 SU ENCAMPMENT HEALTH & SAFETY PLAN to OUTDOOR PROGRAM MANAGER
2-4 WEEKS PRIOR:
 WATERFRONT RESERVATION FORM -and lifeguard certifications sent to
Outdoor Program Asssistant
UP TO 2 WEEKS AFTER ENCAMPMENT:
 PROPERTY USE REPORT to OUTDOOR PROGRAM ASSISTANT
 SU ENCAMPMENT FINAL REPORT to OUTDOOR PROGRAM MANAGER
 SU ENCAMPMENT FACILITY USAGE REPORT to OUTDOOR PROGRAM MANAGER
Rev 4/28/16
Please send a copy of this report at least 4 weeks before the date of your encampment to the Director Camp and Travel Pathways.
Service Unit _____________________________________________ Encampment Director__________________________________________
Site/Program Center ______________________________________ Encampment Dates____________________________________________
Expected # of Troops ______________
Total Girls _____________ Boys ______________ Women ______________ Men ______________
I understand that each program center has a maximum capacity for the site and that each building/tent also has a maximum capacity for sleeping.
This information has been provided to the troop leaders attending the Service Unit Encampment and we will not exceed those capacities.
The following have been completed: Please check:
 A written plan for fire, evacuation, severe weather, lost camper, and security have been developed and distributed to all participating troops
and support staff. Method of Distribution: _____________________________________________________________________________
 We have a LEVEL II first aider for these groups on site OR a LEVEL I first aider with each troop and a designated first aider to lead an
emergency plan if necessary.
LEVEL II FIRST AIDER:___________________________________________ CERTIFICATION:_________________________
DESIGNATED LEVEL I FIRST AIDER:________________________________ CERTIFICATION:_________________________
 In the event of an emergency, communication procedures and the chain of command have been discussed with all leaders.
 A fire/evacuation drill is planned for:__________________________________________________________________________
 All support staff for food services, waterfront, and other program activities have the appropriate training and certifications as defined by
GSUSA Safety Activity Check Points 2010 and Girl Scouts of NYPENN Pathways.
 Emergency numbers are posted by all telephones including Ambulance, Fire, Police, and Poison Control, or plans have been made to
post. (Provided at all Girl Scouts of NYPENN Pathways properties).
 If planning waterfront activities, all waterfront personnel certifications have been checked:
Lifeguard name________________________________________________ Telephone (
) ________________________
Certification(s)_____________________________ CPR:________________________ Exp. Date_______________________
Boating Instructor Name _________________________________________ Telephone (
) ________________________
Certification or Documented Experience:_____________________________________________________________________
For All NYPENN Properties: Health Department approval for lifeguard certifications has been obtained.
Ratio is 1 Lifeguard - 25 girls plus 2 adult watchers at all waterfront activities. The waterfront ratio adults to girls is 1:10, not counting lifeguards.
 Additional activity insurance has been purchased for people who are NOT registered Girl Scouts and will be participants in the program.
(Request due two weeks prior to encampment)
Report submitted by: _____________________________________________________ Telephone (_________) ___________________________
Rev 9/30/15 rw
There is a Waterfront Rental Charge for most Program Centers. Please see Camp Rental Fees and Information Sheet for prices.
Adventure Center (camp) waterfront areas, if reserved and weather conditions are appropriate, will be available between May 23 and
September 18 for swimming, and May 2 and October 14 for boating.
The waterfront area will be marked off with buoy lines and docks.
A checkout system will be available (buddy board). All equipment including PFDs will be available for lifeguards and participants.
Refer to “Safety Activity Checkpoints” on our website for supervision and ratio requirements for swimming and boating.
CHOOSE THE CAMP/ADVENTURE CENTER LOCATION:
Amahami (offers: swimming, canoes, rowboats, kayaks, paddleboats)
Comstock (offers: swimming, rowboats, canoes)
Hoover (offers: swimming, canoes, rowboats, kayak, paddleboats)
Trefoil (offers: swimming, rowboats, canoes, paddleboats, kayaks)
Choose which waterfront activities you will need:
Date of Use: _____/_____/_____ - _____/_____/_____
Swimming
 Boating including: Rowboats Canoes Paddleboats Kayaks
Person in Charge: _____________________________________________________________________
Troop #/Group/Service Unit _____________________________________________________________________________________________________________
Before use of the waterfront is granted the following certifications must be
submitted & approved by the Outdoor Program Manager & the local Health Department.
SWIMMING
* Waterfront Lifeguarding AND CPR for the Professional Rescuer
At least one adult lifeguard (must be 18+ years old) is needed
Phone Number: (_______)_______________________Age______________
CANOEING/ROWBOATING/KAYAKING
**Adult (must be 18+ years old) Instructor certified in craft to be used or person
trained and certified in small craft safety or equivalent.
And
* Swiftwater Safety & Rescue and Advanced Swiftwater Safety & Rescue OR
* Waterfront lifeguarding AND CPR for the Professional Rescuer
Email: ________________________________________DOB ___/___/____
Name: _______________________________________________________
Name: _______________________________________________________
Phone Number: (_______)_______________________Age______________
Phone Number: (_______)_______________________Age______________
Email: ________________________________________DOB ___/___/____
Name: _______________________________________________________
Email: ________________________________________DOB ___/___/____
Name: _______________________________________________________
Phone Number: (_______)_______________________Age______________
Email: ________________________________________DOB ___/___/____
Name: _______________________________________________________
Phone Number: (_______)_______________________Age______________
Email: ________________________________________DOB ___/___/____
I will see that the required personnel are present and the equipment reserved is used appropriately and returned as directed. I am enclosing a
copy of the current certification(s) indicating name(s) and training taken, and dates for First Aid, CPR/FPR, Waterfront Lifeguarding or
boating certifications. I also understand that, while boating, PFDs must
be worn by all persons at all times, safety rules must be followed, and a
Credit Card Authorization: (Please Print)
designated buddy/checkout system must be used. I understand that the Please charge payment of: $________________
Chip card? yes no
rental fees may be shared with other troops using the site at the same
Choose one:
 MasterCard
 VISA
 Discover Card
time.
Acct #
______________________________________________
Signed: _______________________________________________________
Card exp. date:
____________ CVV #_____________ Zip____________
Phone #: _________________________________ Date_________________
PLEASE MAKE CHECKS PAYABLE TO GIRL SCOUTS OF NYPENN PATHWAYS
Rev 2/10/16
Service Unit__________________________________________ Coordinator_____________________________________________
Telephone________________________________ Dates of Use_______________________________________________________
Attendance #s: Girls: DA:____ BR:____ JR:____ CD:____ SR:____ AMB:____
Program Center:
Women:____
Amahami Cicero Activity Center Comstock Hoover
Boys:____
Men:____
Trefoil
Directions:
Day Use: If all the troops participated in a program at the designated facility, put ALL in the troop/group # column. If only some of the
troops used that facility, please list the troop number(s) individually.
Overnight Use: Please list which troops stayed in which facilities during your encampment. This is in addition to day use.
FACILITY
DATE
LIST
TROOP/GROUP
DAY USE
ONLY
#
NIGHTS
#
GIRLS
#
BOYS
#
WOMEN
#
MEN
Rev 9/26/2015 4:19 PM rw
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Rev April 28, 2016 rw