Program Assistance Grant Application Form - Girl Scouts Of Central Indiana Page 3
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3Program Assistance Grant Application
Girl Scouts of Central Indiana
Section V: Budget
Total anticipated cost
Total amount girl/troop can pay
If other, please specify
Transportation ___________ Troop _________________________
________________________
Camp fee _______________ Parent/guardian _________________
________________________
Program fee _____________ Girl’s earnings ___________________
________________________
Other __________________ Other _________________________
________________________
Total ___________________ Total _________________________
________________________
Total amount requested ____________________________________
Total annual income: (Please check the appropriate amount)
q $0-$12,000
q $15,001-$18,000
q $21,001-$25,000
q $30,001-$40,000
q $50,001-$60,000
q $12,001-$15,000
q $18,001-$21,000
q $25,001-$30,000
q $40,001-$50,000
q Over $60,000
Number of people supported by this income: _____________________________________________
Answer the following questions. Please attach additional sheet if necessary.
What is the trip goal? ________________________________________________________________
Are there any special circumstances?
(This question must be answered in order for your application to be considered.)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Is the parent/guardian a troop leader? ___________________________________________________
The following questions must be filled out for processing:
Does your child receive free or reduced lunch?
☐ Yes
☐ No
_____________________________________________________________
What is your child's school district?
Please allow 4 weeks for processing.
Award amount ___________ Requisition # ____________
63
63
2016
CAMP GUIDE
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