Request For Financial Assistance For Girl Members - Girl Scouts Of Connecticut
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1GIRL SCOUTS OF CONNECTICUT
1-800-922-2770
R
F
A
G
M
EQUEST FOR
INANCIAL
SSISTANCE FOR
IRL
EMBERS
Mail completed form to:
Girl Scouts of Connecticut
•
Please submit completed form six (6) weeks in advance of need.
Attn: Financial Assistance, CONFIDENTIAL
20 Washington Avenue
Incomplete forms delay processing.
North Haven, CT 06473
Phone (203) 239-2922 Fax (203) 234-6828
Girl Information
Girl Name
Date of Birth
Grade
ST
Zip
Mailing Address
City
Phone
Level
Participated in Council Product Sales
D
B
J
C
S
A
Yes
No If no, why not?
Troop/Group Leader’s Name
Service Unit
Work Phone
Home Phone
Cell Phone
Email
Mailing Address
City
ST
Zip
# Girls in Troop/Group
Dues per girl
Troop/Group #
Family Information
(Single-parent families should list only the custodial parent.)
Parent/Guardian Name
Parent/Guardian Email
Employed by
Title/Occupation
Parent/Guardian Name
Parent/Guardian Email
Employed by
Title/Occupation
Name/Work Phone
Name/Home Phone
Name/Cell Phone
Active duty military parent/guardian?
Yes
No
# Children
Ages
# Other dependents
Do you receive any of the following? (Check all that apply.)
AFDC
SSI
Social Security
Housing subsidy
Subsidized meals
Gross Family Income
$0-$24,999
$25,000-$34,999
$35,000-$44,999
$45,000-$54,999
$55,000-$64,999
$65,000-$74,999
$75,000 & above
Please check boxes below for extra expenses which affect your financial needs.
Medical/Dental
Legal
Education
Debt
Single Income
Loss of Job
Disability
Other ____________________________________________________________
Please explain special circumstances checked above. (Attach additional explanation if necessary.)
I have read the guidelines above, and all of the information I have listed is true and accurate to the best of my knowledge.
Parent/Guardian Signature _______________________________________________
Date __________________________________________________________________
Financial Request (Upon approval, checks will be sent to the recipient's Troop/Group Leader.)
Uniform Components and Girl Scout Program Resources
Troop/Group dues
(To be completed by parent/guardian and/or Troop/Group Leader.) A voucher for store merchandise, upon approval,
Troop/Group dues per meeting
Check the voucher for expiration date.
will be issued to the Troop/Group Leader for redemption at a council shop.
(Abbreviations: T=Traditional, C=Contemporary, R=Regular, L=Long, GGGS= Girl’s Guide to Girl Scouting,
Number of meetings
World= It’s Your World-Change It!, Planet= It’s Your Planet-Love It!, Story=It’s Your Story-Tell It!)
Total cost of dues
Troop/Group Numerals _____________ Council ID Strip ________________________________________________________
Daisy
Tunic (Size 6-7 or 8-10) _____
Pin
Journey Book _______________
Journey Award _____________
6-7
Amount family can pay
GGGS
Petals/Leaves____________________
Other ____________________________________________________
Brownie
Sash (R or L) ___
Pin
Journey Book ______________________
Journey Award __________________
R
GGGS
Badges ________________________
Skill Builder set____________________
Other __________________
Total amount requested
Junior
Sash (R or L) ___
Pin (T or C) ___
Journey Book _____________
Journey Award __________________
T
R
GGGS
Badges________________________
Skill Builder set____________________
Other __________________
Cadette/Senior/Ambassador
Sash (R or L) ___
Pin (T or C) _____
Journey Book _________________________
T
R
Journey Award _____________________
GGGS
Badges ________________________________________________
Skill Builder set (Cadette/Senior)_______________________
Other _________________________________________
Additional Comments: ______________________________________________________________________________
___________________________________________________________________________________________________
Program Events, Trips, and Training
(Please attach pertinent information, such as event flier, etc.)
Amount from Other
Amount
Name of Event
Location
Date
Cost
Amount Approved
Sources
Requesting
Event
Trips/destination
Other
For Office Use Only
Total amount requested ________ Total amount approved ________ Processed by ________ Date ________ Voucher $ ________
Internal transfer to acct.#____________________
Notice of fee waived _________________________
Assistance sent to (specify name and position): Troop/Group Leader___________________ Event/Program/Training Coordinator______________________ Date sent ____________
Request for Financial Assistance for Girl Members – 12/15/11
(Reviewed 10-24-14)
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