Adult Member Registration Form - 2016-2017

2016-2017 Adult Member Registration Form

Farthest North Girl Scout Council  Council Code: 600 Adul t Membershi p $15 per Girl Scout Year

PLEASE PRINT CLEARLY 

MEMBERSHIP

Troop #:

or Individual

Service Unit:

ID#

EXPIRATION

New Member (first time registering)

Re-registering

Lifetime Membership (Information update, no dues required)

9 - 30 - 2017

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

no

Name:

E-mail:

Employer:

Position:

Work Phone: (

)

Cell Phone*: (

)

Troop #:____________________________________________

Position with Troop:

Troop Leader

Troop Helper

(check only one)

Assistant Troop Leader or Co-Leader

Troop Cookie Manager

Troop #:____________________________________________

Position with Troop:

Troop Leader

Troop Helper

(check only one)

Assistant Troop Leader or Co-Leader

Troop Cookie Manager

Other Position/s (check all that apply):

Volunteer

Council Staff

Service Unit Team Member

Board Member

Board Committee Member

Trainer

Nominating Committee Member

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.

Race/Ethnicity/Language

A. Mark one

B. Are you Hispanic/Latino?

Alaskan Native

Hawaiian or Pacific Islander

(Complete A, B & C)

or more:

American Indian

Caucasian

yes

no

Asian

Other

(Complete A and B)

yes

C.

African American

First language, if not English:_______________

Birthdate:

/

/

My age range is:

18 - 29

30 - 49

50 +

MM

DD

YYYY

(Optional)

Annual House Income: (Optional)

$50,000 to

$100,000+

<$50,000

My daughter qualifies for free or reduced-price lunch.

$100,000

(check one)

.

I would like to contribute:

$25.00

$50.00

$100.00

Credit Card #_________________________ Exp. date:_______

$150.00

$200.00

Other: $______

Signature:___________________________________________

___

st

I would like to register as a Lifetime Member $375

Girl Scout Ambassador graduating High School Lifetime Membership $195

(Must submit by Sept. 1

)

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

We acknowledge that the registrant will make the Girl Scout Promise and accept the Girl Scout Law. The registrant has our permission to join Girl Scouts. We

understand that when participating in Girl Scout activities the registrant may be photographed for print, video, or electronic imagine. We understand that the images

may be used in promotional materials, news releases, and other published formats for either the local Girl Scout Council or Girl Scouts of the U.S.A. We acknowledge

that the images will be the sole property of either the local Girl Scout Council or Girl Scouts of the U.S.A.

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.

Cash____________

CK#____________  

Charge__________

Financial Aid ____________

Troop

Camp

Staff

Board

Indiv.

Other

Office Use Only: Date Received:

Initials:

Receipt #

E-Council Entry: