JULIETTE PROGRAM CREDIT REIMBURSEMENT FORM
To be reimbursed for Girl Scout expenses please submit the following with this form. Please allow at least three weeks for processing.
Juliette Program Credit
Copies of receipt(s) for expenses
Date: ________________Girl Scout Name: _____________________________________________________________________________ Grade: __________
Parent/Guardian Name: ______________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________________________
Phone: ______________________________________________________
$_________________ Amount of Juliette Program Credits Submitted
Checks will be made payable to “Parent/Guardian of GIRL NAME” and mailed to the address listed on this form unless otherwise specified.
Please make check payable to: _______________________________________________________
Mailing Address: ________________________________________________________________________________________________________________
Please check here if you are a Juliette joining a troop and are submitting your Juliette Program Credits for a check made out _______________
to your new troop. Check should be made payable to TROOP # __________________________ and mailed to the following address:
______________________________ _____________________________________________________
Itemized list of expenses
(please submit supporting documentation: receipts, registration, and/or order forms.)
Supply/Item/Activity
Amount
EXAMPLE: Fleece for making blankets (Sew Easy Badge)
$15
Description of Girl Scout Activity:
How does this expense relate to Girl Scouts? Name of badge/patch/Journey this activity is related to (if applicable):
Girl Signature:_______________________________________________
Signature of parent/guardian or Juliette advisor:____________________________________________________________________________________
Print completed form and mail with deposit to:
Please keep a copy for your records.
Girl Scouts of Minnesota and Wisconsin River Valleys
Juliette Program Credits are not transferable.
St. Paul Service Center
Incomplete forms will be returned and result in a processing delay.
400 Robert Street South
Please allow at least three weeks for processing.
St. Paul, MN 55107
For office use only: Received date:_______________
Processed Date:_______________
Check Request Amount:________________________
Approval Signature________________________________________________ Date: _________________
09/13
Girl Scouts of Minnesota and Wisconsin River Valleys • 400 Robert St. South, St. Paul, MN 55107 • 800-845-0787 • Girl