Financial Aid Form - Girl Scouts Of Northern California - 2017

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2017 Financial Aid Form
STEP 1: READ THE FINANCIAL AID INSTRUCTIONS
STEP 2:
COMPLETE THE ENTIRE APPLICATION AND SUBMIT IT WITH PROOF OF INCOME – PLEASE PRINT CLEARLY!
I am applying for fi nancial assistance for:
One selection per application. Please do not add other selections.
Uniform Voucher (To obtain a Sash or Apron if Daisy, GS Membership Pin, Council ID patch set or set of Troop Numbers)
Camp (Day or Resident)
Destination
Council Program/Event
Extended Travel
The following information MUST be completed for all applicants.
Girl’s Name
INCOMPLETE APPLICATIONS WILL NOT BE REVIEWED.
(One application per girl. Aid is for girl participants only.)
PROOF OF INCOME IS REQUIRED.
Address
Number of children living at home
Ages
City
County
State
Zip
CA
Number of adults dependent on family income
Birthday
School Grade in Fall
Gross monthly income
School Name
Annual household income level:
Is she a registered Girl Scout?
Yes
No
Below $18,000
$42,001 – $48,000
If yes,Troop #
or
Juliette (Individually registered Girl Scout)
$18,001 – $24,000
$48,001 – $54,000
Has she received fi nancial assistance from Girl Scouts of Northern California
$24,001 – $30,000
$54,001 – $60,000
before?
$30,001 – $36,000
$60,001 – $80,000
Yes
No
$36,001 – $42,000
$80,001 – $100,000
Parent/Guardian 1 Name
Over $100,000 may qualify under very special circumstances only.
Phone (
)
Attach verifi cation of income from all sources (pay stub, tax return, proof of
assistance, etc.) to this application.
Email
(Providing your email is the most effi cient and cost effective way to notify you of the outcome.)
This section DOES NOT apply to uniform voucher requests
Employment
Program Name
(REQUIRED) If not applicable please explain
(Write name of program or event exactly as listed in guide or online)
Parent/Guardian 2 Name
Camp Name
Camp Session
Phone (
)
(For Day Camp requests only—1 CAMP SESSION PER APPLICATION)
Email
Start Date
End Date
(Providing your email is the most effi cient and cost effective way to notify you of the outcome.)
Did she register online?
Yes
No Registration #
Employment
Camp/Program/Event Fee
(DO NOT ADD OTHER FEES)
$_____________
(REQUIRED) If not applicable please explain
Girl lives with:
Amount parent/guardian can pay
$_____________
Mother only
Father only
Both parents
Other guardian
Amount girl can pay (including Fall/Cookie Rewards)
$_____________
If other please specify
Amount from other sources
$_____________
Amount requested
(REQUIRED)
$_____________
Please indicate any special circumstances that relate to this request;
(additional pages may be attached)
STEP 3: FUNDING RELEASE AND SIGNATURE
I certify that all of the information on this application and the supporting documents are true and complete. CAMP RELEASE: The Guardsmen Campership Program provides funding for
a portion of our GSNorCal camperships. In consideration of this campership application for sponsorship by The Guardsmen, I agree to the following conditions: (1) to allow my child to attend
camp; (2) to contribute the amount of money specifi ed for my child to attend camp; (3) to allow my child to receive such medical treatment as may be considered necessary; and (4) The
Guardsmen shall not be responsible for any disease, injury or death to my child while traveling to, from or while attending camp.
Parent/Guardian Signature
(REQUIRED)
Date
GIRL SCOUTS OFFICE USE ONLY
STEP 4:
RETURN COMPLETED APPLICATION - NO CELL PHONE PICS!
(DO NOT SUBMIT WITHOUT PROOF OF INCOME)
Date Received:
Girl Scouts of Northern California, Attn: Financial Aid
408-287-8025
By Mail:
By Fax:
Date Approved:
1310 South Bascom Avenue, San Jose, CA 95128
Amount Approved:
For questions, call 408-287-4170, EX 6012
Approval Signature:
NOTE: INCOMPLETE APPLICATIONS WILL NOT BE REVIEWED AND CAMP SPACE WILL NOT BE HELD.
PLEASE ALLOW UP TO 4 WEEKS FOR APPLICATION PROCESSING.
ALL INFORMATION ON THIS APPLICATION IS TREATED CONFIDENTIALLY AND SHREDDED AFTER USE.

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