Financial Assistance Request Form - Girl Scouts Of The Missouri Heartland
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1Girl Scouts of the Missouri Heartland, Inc.
Financial Assistance Request
for volunteer training
Please complete this form in its entirety and attach it to the Training Registration Form. Forms must be
received no later than the training registration deadline.
Request for:
Name _________________________________ Address ____________________________________
City ____________________ County _____________________ State _______ Zip _____________
Phone ________________________ E-mail ______________________________________________
Girl Scout Affiliation (check all that apply)
Program Age Level
□
□
Leader or Co-Leader of Troop Number _______
Girl Scout Daisy (grades K-1)
□
□
Registered Adult of Troop Number __________
Girl Scout Brownie (grades 2-3)
□
□
Service Team Member
Girl Scout Junior (grades 4-5)
□
Service Unit Number: _________________
Girl Scout Cadette (grades 6-8)
□
Position: ___________________________
Girl Scout Senior (grades 9-10)
□
□
Facilitator
Girl Scout Ambassador (grades 11-12)
□
Other __________________________________
Assistance Type
Amount Required/Fees
Amount Requested
□
Volunteer Training
$ __________________
$ _______________
Name of Training: _____________________________________________________________
Date of Training: ______________________________________________________________
Reason(s) for Financial Need
□
□
□
Annual Household Income:
$0 - $20,000
$20,001 - $30,000
$30,001 - $40,000
□
□
□
$40,001 - $50,000
$50,001 - $60,000
$60,001 and up
Number of Household Members: ____________ Other pertinent information: _____________________
__________________________________________________________________________________
__________________________________________________________________________________
Requestor Information
Name ___________________________ Relationship to individual listed above ___________________
Daytime Phone Number ____________________ E-mail_____________________________________
It is our goal that no girl be turned away due to a financial need. We receive many requests for assistance throughout the
entire year. If you can pay a portion of the fee, please enclose that portion with your request, so our funding can benefit girls
throughout the entire year.
□
□
For Office Use Only: Approved
Denied
Reason for Denial ____________________________________
Amount Approved $ ________ Date Approved _________ RM _________ GL 8915 Dept ___________________
Reg’d _________________________ LLS________________________________________________________
Girl Scouts of the Missouri Heartland, Inc.
877-312-4764 ● ●
P:\GSMOHEARTLAND DATA\Forms\Financial Assistance 10/29/12
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