GIRL SCOUT MISSION
Membership Registration Summary
Girl Scouting builds girls of courage,
confidence, and character, who
Membership year through 9/30/2018
make the world a better place.
GRP/TRP
SU/TEAM AREA
AREA
COUNCIL CODE
CHECK ONE
�
�
New Group
Renewing Members
COUNCIL USE ONLY
Form completed by: (check one)
� Volunteer
� Staff
Summary/Receipt #:
Name: First
Last
Batch Date:
/
/
(
)
Phone Number
E-Mail
Batch #:
Check the one term that best describes the primary way these girls are registering:
Program Name:
� Group (same group of girls participating together such as a troop or series)
� Individual (girls will participate in one or multiple ways, not as part of a long-term group)
Start Date:
Program Duration (Check one):
Location:
� 8–12 months
� 4–7 months
� 1–3 months
� 1–4 weeks
� 6 days or less
Account Code:
Program Frequency (Check one):
� Daily
� Weekly
� Every other week
� Monthly
� 1–3 times annually
Release of Funds:
Check the level that best describes the majority of girl registrants in the group:
� Grade K–1 (Daisy)
� Grades 2–3 (Brownie)
� Grades 4–5 (Junior)
� Grades 6–8 (Cadette)
� Grades 9–10 (Senior)
� Grades 11–12 (Ambassador)
� Multi-Grade
Meeting Place (Check one):
Meeting Day, Time, and Location (Fill in all.):
� Public facility
Day:
� Home
Start time:
End time:
� School
Name of meeting place:
� Religious building
� Other organization facility
Address:
� Council facility
� Other
Annual Registrations:
Lifetime Registrations:
# of Girls:
(x $25 each)=
# of Lifetime Membership*:
(x $400 each)=
# of Adults:
(x $25 each)=
# of Young Alumnae**:
(x $200 each)=
Total Amount of Fees: $
Total Amount of Fees: $
Donations Received: $
Donations Received: $
Other: $
Other: $
Total Amount Attached: $
Total Amount Attached: $
Membership fees in Girl Scouts of the USA (GSUSA)
*An adult 18 years or older who is not a former girl member or a former
are not refundable or transferable
girl member who is 30 years or older
**Must be a former girl member between 18 to 29 years old
Count the number of times each payment is used, and total the amount of each payment type attached:
Please complete this form
PAYMENT
COUNT
TOTAL AMOUNT
PAYMENT
COUNT
TOTAL AMOUNT
and attach completed member
Cash:
#
$
Check(s):
#
$
registration forms and payment
Amex:
#
$
Discover:
#
$
for the total amount of fees.
Please be sure to note additional
Visa:
#
$
MasterCard: #
$
payments or contributions in
Other:
Specify
#
$
the space provided and return to
Other:
Specify
#
$
your local council representative.