Camp CEO 2023 Mentor Registration Form

Mentors are the heart of Camp CEO. Thank you for sharing your story, your time, and your talents. Your generosity can inspire the next generation of women leaders! Please complete this form in full so we have all the necessary information prior to the Camp CEO program in October.

If you have any questions please contact Glynnis Hokenson at ghokenson@girlscoutsgcnwi.org.

First name *

Last Name *

Company Name/Organizational Affiliation *

Title *

Email Address *

Phone Number (Preferred) *

Preferred Phone Type *

Phone Number (Alternate)

Street Address *

City *

State *

Zip Code *

Personal Assistant Name (if applicable, for scheduling purposes)

Personal Assistant Email Address

T-Shirt Size *

To promote the participation of girls from various racial and cultural backgrounds, you have the option of providing the following self-identifying information. This information will be used for data purposes exclusively and will have no influence on the selection process. (Optional)

Camp CEO Scheduling

When would you be able to engage with our Girl Scouts at Camp CEO? (Please check all that apply) *

Saturday, October 7 - All Day

Sunday, October 8 - All Day

Saturday and Sunday, October 7 & 8 - All Day both days

I plan to stay overnight at Camp on Saturday, October 7 (encouraged but not required)

Other. Please Explain. Other. Please Explain.

Please tell us more about you.

Which of these career fields do you best fit in? (Select all that apply) *

What are your favorite hobbies/special interests? (pick your top 3) *

Provide your personal mission statement (40 words or less). *

0/40 words

What does leadership mean to you? *

What advice would you give to your younger self? *

Why are you interested in volunteering as a mentor at Camp CEO? *

Please provide a link to LinkedIn profile, bio on corporate website, or other online listing that provides additional information about you:

Health Information

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Are there any major health conditions that we should know about in the event of an emergency (i.e. asthma, seizures, diabetes, heart problems)?

Please list any allergies or dietary restrictions that we may need to be aware of.

Name of Physician

Physician Phone Number

Any photographs or films taken in which the registered adult appears may be used for promotion or as deemed appropriate by the Girl Scout council free of any claims on my part. *