Form Pg310 - Individual/wider Opportunity Financial Assistance Request - Girls And Adults
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1Mail to:
Girl Scouts – North Carolina Coastal Pines
6901 Pinecrest Road, Raleigh, NC 27613
1‐919‐782‐3021 or 1‐800‐284‐4475
I
/
O
F
A
R
– G
A
NDIVIDUAL
WIDER
PPORTUNITY
INANCIAL
SSISTANCE
EQUEST
IRLS AND
DULTS
_________________________________________________________________________________________________________________________________________________________________________
Financial assistance is a supplementary way for a registered girl or adult with demonstrated need to
Office use only–Transfer
participate in all aspects of the Girl Scout program. Financial assistance is granted based on the
Amount Granted: ______
information provided and availability of funds. Parents should complete this form for a girl applicant.
Account # Dept. #
Use a separate form for each applicant. Applications are due on the first of each month.
8900
_____
8910
_____
Name
Girl
Adult
Address
City
Zip
Day Phone (
)
‐
ext.
Evening Phone (
)
‐
Troop Number
County/Area
Grade Level:
D
B
Jr
Cad
Sen
Amb
Adult
(Adult) Girl Scout Volunteer Position (if applicable)
(Girl) Name of Parent/Guardian
:
Type of Assistance Requested
Troop Trip*
Area/County Event**
Destination
* A Troop trip must be granted Wider Op Status before individual financial assistance applications can be considered.
** Please attach an event flyer for area/county events. Attach registration form for council‐sponsored events.
Trip destination and Dates:
Name of event/program and location/Date:
Name of Adult Training/Date(s):
Basic Information:
A. Total number of family members
(include individual making request)
B. Total family income:
under $15,000
$15,000 ‐ $24,999
$25,000 ‐ $34,999
$35,000 ‐ $49,999
$50,000 ‐ $74,999
$75,000 ‐ $99,999
over $100,000
Yes
No
C. Did you or are you currently participating in this year’s Cookie Sale Program?
D. Have you received financial assistance from this council before?
Yes
No
If yes, name of Event/Trip
Amount and Year received
E. Do you owe money to Girl Scouts – North Carolina Coastal Pines?
Yes
No
F. Are you a registered Girl Scout with Girl Scouts – North Carolina Coastal Pines?
Yes
No
G. Reason for requesting financial assistance. Describe the need for the request on the back of this form
or on a separate piece of paper. Be specific (i.e. loss of job, unexpected medical expenses, etc.).
A. Event/Trip fee per girl/adult (do not include personal spending money)
$
Cost:
B. Troop contribution to individual (if applicable)
$
C. Amount you will contribute toward this opportunity
$
D. Amount of Financial Assistance Requested*
$
*Wider Opportunity Committee grants funding to qualified individuals based on information provided, need, and availability of
funds. The basic guideline is up to one‐third the cost of the event fee and transportation, not to exceed $750.00. Requests for
troop trips and destinations are due the first of each month.
Adult Applicant or Parent/Guardian (for girl applicant) Signature
PG310/06-17
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