Girl Scouts Of The Colonial Coast Girl Financial Assistance Request Summer Camp Form
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1Girl Financial Assistance Request – Summer Camp
Use this form to request financial assistance for a girl to participate in summer day camp or resident camp. Financial
assistance is granted based on the information provided and availability of funds.
Complete this form in its entirety and return to the Council office along with camp registration form and $25 non-
refundable deposit. If paying by check, make payable to GSCCC.
Complete a separate form for each girl applicant and submit 30 days prior to the camp session start date.
Return to: Girl Scouts of the Colonial Coast
912 Cedar Rd
Chesapeake, VA 23322
Camper’s Full Name
First
Middle
Last
Address
City
State
Zip
Mother’s Employer
Mother/Guardian Name
Email
Day Phone
Evening Phone
Father’s Employer
Father/Guardian Name
Email
Day Phone
Evening Phone
Name of Camp Session
Date of Session
Location
Reason for requesting financial assistance. Please explain (e.g., medical expenses, unemployment, decrease in income, etc.).
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Do you qualify for the following? (Check all that apply.)
TADF/Welfare
School free lunch
School reduced lunch
Camper participates in Girl Scouts as:
Individual member
Troop member (Troop #____________)
Has your camper participated in the Council’s most recent product sales programs?
Fall Products
Cookie Program
Has your camper received financial assistance from Girl Scouts of the Colonial Coast in the past?
Yes
No
Family size:
4
5
6
7
8
Other: _____
Complete fields below to determine amount of requested grant.
Camp fee:
$ __________
Less the non-refundable $25 deposit*: – $ __________
25
Less the amount the family can pay: – $ __________
Less payment with Cookie Credits: – $ __________
Total grant requested: = $ __________
*Note: Camper cannot be registered for a camp session until $25 non-refundable deposit is paid.
Applicant will be notified of remaining balance due. Balance due 30 days prior to camp session start date.
Applicant’s Signature ________________________________________________ Date __________________________
Office Use Only
Service Unit # __________
Amount Granted $ _______
____________
Issue Date
Rev 05/2016 Property
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Parent category: Business