Fillable Adult Member Registration Form - 2015-2016 printable pdf download

2015-2016 Adult Member Registration Form

PLEASE PRINT CLEARLY IN INK.

MEMBERSHIP

Troop #:

or Individual

Service Unit:

ID#

EXPIRATION

New Member (ﬁrst time registering)

Re-registering

Lifetime Membership (LTM update, no dues required)

9 - 30 - 2016

Female

Male

Number of years in Girl Scouts as a girl:____________________ as an adult:____________________

Ms.

Mrs.

Miss

Mr.

Last name while girl member:

First Name:

Middle Name:

Last Name:

Mailing Address:

Apt. #:

PO Box:

City:

State:

Zip:

Phone: (

)

Check if this is a new address within the last year.

Previous Address:

Check if your name has changed in the last year.

Previous Name:

Do you have a spouse or life partner?

yes

Name:

E-mail:

I wish to opt in:

texts

emails

Employer:

Position:

Work Phone: (

)

Cell Phone: (

)

Troop #:____________________________________________

Role with Troop:

Troop Leader

Troop Cookie Manager

(check only one)

Friends and Family Member

Troop #:____________________________________________

Role with Troop:

Troop Leader

Troop Cookie Manager

(check only one)

Friends and Family Member

Other Role/s (check all that apply):

Non Troop Afﬁliated Volunteer (14)

Council Staff (21) Exempt

Service Unit Team Member (11)

Council Board/Board Committee Member (16)

Council Staff (22) Non-exempt

Facilitator (12)

Council Nominating Committee Member (17)

Other:_______________________________

By completing the following optional questions, you can help ensure community support and funding for Girl Scouts. Girl Scouts respects and welcomes people from all

backgrounds and abilities. This information is used for statistical purposes only. Thank you for providing the information requested.

A. Mark one

B. Are you Hispanic/Latino?

Race/Ethnicity/Language

African

Hawaiian or Paciﬁc Islander

(Complete A, B & C)

or more:

American Indian or Alaskan Native

White

Choose not to share

yes

Asian

Other

(Complete A and B)

yes

Black or African American

First language, if not English:_______________

Choose not to share

Birthdate:

My age range is:

18 - 29

30 - 49

50 +

YYYY

I have the following disability/disabilities:

Developmental

Hearing

Learning

Physical

Visual

Other:___________________________________

(Check all that apply)

If you need special accommodations please contact River Valleys at 800-845-0787.

Annual Household Income:

Less than $15,000

$15,000 to $34,999

$35,000 to $49,999

# of people in household ___________

$50,000 to $74,999

$75,000 to $99,999

$100,000 or more

Choose not to share

I would like to register as a Lifetime Member. My check for $375 is enclosed/attached.

Please send me information about becoming a Lifetime Member.

I am requesting assistance with the $15 annual national membership dues. I can pay $_________ toward the $15 dues.

I am willing to join Girl Scouts. I understand Girl Scouts of the USA (GSUSA) national membership is $15 per year. I have read the information above and have

answered each question to the best of my ability. Checks accepted only upon condition customer agrees if any check is returned unpaid, a $30 service fee will be

added to all dishonored checks. A debit for the amount of the check and the $30 service fee may be processed electronically without further notice to customer.

Additional civil penalties may be imposed on checks returned for non payment after 30 days. Collection Resources 800-950-7188.

Signature: _______________________________________________________________________

Date:__________________________________________________

Data Privacy Policy: Girl Scouts is committed to respecting the privacy of our members. We do not sell or trade membership lists, contact information, or any other personal data

about individual members for any reason.

Membership Fee: $ __________________ Donation __________________ Total Attached: $ __________________

cash:_________

CK#:_________

Other:________________

Grant:_________

Camp

Event

Series

Travel

Troop

Discover