Meeting in the Home Form

An application and approval are required for any Girl Scout troop meetings or activities that will be held in a private residence. All adults (18 and over) living and or staying in the home must have an approved background check screening on file with Girl Scouts of Southern Arizona (GSSOAZ). The residence must have Homeowner’s or Rental insurance. Allow 4 weeks for processing. Meetings or activities may not be held in a private residence until approval has been received.

Please review Guidelines for Girl Scout Meetings and/or Activities in a Private Residence below before filling out the form.

Troop Number*

County:*

Name of Volunteer (Leader/Co-leader) in charge of group:*

Email of Volunteer in charge of group: *

example@example.com

Please list the names (first and last) and email addresses of all adults (ages 18+) who live in the home (spouse, partner, grandparent, adult children, etc.):*

Street Address of Home*

City*

State*

Zip Code*

Initial each of the following items to acknowledge that you have read and understand guidelines and policy.

A minimum of two unrelated adults (one of whom must be female), plus any additional adults needed to meet Girl Scout/adult ratios will be present during the entire meeting/activity.*

Initial

All youth participants are currently registered Girl Scouts; all adult leaders/co-leaders are approved volunteers with an approved background check screening on file with GSSOAZ and are current Girl Scout members.*

Initial

Written permission for each Girl Scout to attend a meeting/activity in a private residence including caregiver permission form for activity or trip, emergency information, health history and permission for medical treatment are on file at the home of meeting/activity.*

Initial

All people 18 years and older living and or staying in the home have an approved background check screening on file with GSSOAZ regardless of whether they will be present at the meeting.*

Initial

The residence is accessible to people with disabilities to meet needs of anyone registered in the troop.*

Initial

First Aid kit is on site.*

Initial

Pets are in a safe and secure location completely separate from Girl Scouts while present in the home.*

Initial

Prescription medicine is in a secure location and inaccessible to anyone else.*

Initial

Emergency evacuation plan created and on file.*

Initial

Use the buddy system-Girl Scouts should not be left alone at any time.*

Initial

Tag-a-long insurance policy must be followed- please see Safety Activity Checkpoints:*

Initial

Homeowner’s/Rental insurance coverage is current and covers injuries/medical.*

Initial

Name of Insurer: blanks* Policy # blank*

Type of Activity:

Girl Scout Troop Meeting - One TimePermanent Meeting Location for Troop

I am aware of and agree to comply with all standards in Safety Activity Checkpoints and GSSOAZ policies and procedures for meeting/activity in the home. I have read and understand Guidelines for Girl Scout Meetings and/or Activities in a Private Residence. I understand that only approved meetings and activities following all guidelines with registered members of GSUSA are covered by the GSUSA basic plan insurance. Damage to property is not covered.

Signature of Troop Leader*

Date*

Home Approved

If approved, type YES. If not approved, leave blank.

Home application NOT approved

If not approved, type YES.

Home application NOT approved for following reasons:

Signature of Staff*

Date*

Date

Meeting in the Home Form

Meeting/Activity Leader/Advisor Agreement

FOR OFFICE USE ONLY