Adult Membership Registration Form

Adult Membership

GIRL SCOUT MISSION

Girl Scouting builds girls of courage,

Join the global network of 3.2 million Girl Scouts

confidence, and character, who

Membership Year through 9/30/20

make the world a better place.

MEMBERSHIP OPTIONS:

Check one:

 New Member

 Renewing Member

 Lifetime Member

GSUSA ID (if known)

Annual Membership

Title or salutation:

 Annual fee: $15

 Mrs.

 Ms.

 Miss

 Mr.

 Dr.

 Other:

Lifetime Membership

(including permanent membership

Name: First

Middle

Last

card and recognition certificate)

Address

Apartment

 One time fee of $375:

Adults 18 years of age or older

City

State

Zip Code

 One time fee of $195:

(

)

(

)

Girl Scout Ambassadors

Home Phone

Business Phone

graduating from High School

I wish to opt in:  Texts  E-mails

(

)

in this membership year in the

Cell Phone

E-mail Address

month of:

Employer

Title/Occupation

(please submit by Sept. 1st of

graduating year)

Girl Scouts respects and welcomes people from all backgrounds and abilities. By completing the following information (as defined by the US

Census), you ensure support and funding for girls in your community. Hispanic/Latina is defined as an ethnicity, not a race, therefore reported

YES! I

would also like to make a

separately. This information is used for statistical purposes only.

donation today that directly

Gender:

# of years in Girl Scouting:

Date of birth:

Age range:

benefits girls in our area. Enclosed

 Female

as a girl:

/

/

 18-29

 50 and up

is my tax-deductible donation

 Male

as an adult:

mm

dd

yyyy

 30-49

in the amount of: (check one)

Highest education: (check one)

I am: (check all that apply)

I am Hispanic or Latina:

Household income:

 $500

 $250

 $150

 Some High School

 American Indian or Alaskan Native

 Yes

 $0–$14,999

 $100

 $50

 $25

 High School

 Asian

 No

 $15,000–$34,999

 Some College

 Black or African American

 I choose not to share

 $35,000–$49,999

 Other: $

 Associate Degree

 Hawaiian or Pacific Islander

at this time

 $50,000–$74,999

 Bachelor Degree

 White

 $75,000–$99,999

PAYMENT INFORMATION:

 Postgraduate Degree

 Other (please specify)

 $100,000 or more

 I choose not to share

Annual Membership: $

 I choose not to share at this time

at this time

Lifetime Membership: $

I will be participating in Girl Scouting as: (check all that apply)

 Volunteer —I am/will be volunteering for Girl Scouts

 Community Partner

Donation: $

 Parent/Family —I am a parent/guardian/family member of a Girl Scout

 Staff—I am/will be employed by Girl Scouts

Total Attached: $

 Girl Scout Alumnae —I was a Girl Scout, either as a girl, adult or both

 Other

 Cash

 Check*

As a volunteer, I would like to participate in the following role(s):

Representing Group(s)/Troop(s)/Service Unit Numbers:

 01—Advisor or Leader for a Group/Troop #

#

#

#

 Amex  Discover

 02—Assistant Advisor or Leader for a Group/Troop Advisor/Leader

#

#

#

 Visa

 MasterCard

 03—Support Volunteer for a Group/Troop

#

#

#

 Other

 11—Service Team or Unit Volunteer

SU

SU

SU

 12—Learning Facilitator

 Other (specify)

Name on Credit Card

PARTICIPATE WITH GIRLS DIRECTLY : (check all that interest you)

GET INVOLVED “BEHIND - THE - SCENES” : (check all that interest you)

 Camp: Help girls connect with nature during day or

 Administrative: Manage, support and recognize volunteers in

Credit Card #

overnight camp.

your community

 Events: Share your passions during half or full day events.

 Council Committees: Assist in council-wide Girl Scouts

Expiration Date

 Series: Share your interests in a way that fits your schedule

operations

 Travel: Expand girls’ horizons. Travel with girls across town

 Learning Facilitator: Coordinate learning opportunities

or around the world!

 Fund Development: Promote and advance the Girl Scout

Signature

 Troop: Inspire and develop a group of girls on a regular basis.

movement through family and corporate donations

 Virtual: Interact virtually with Girl Scouts everywhere.

Date

Media Permission

The Girl Scout Law

The Girl Scout Promise

*Make checks payable to Girl Scouts

When participating in Girl Scout

I will do my best to be

On my honor, I will try:

activities I may be photographed

honest and fair,

To serve God and my country,

THANK YOU FOR

for print, videotaped, or electronically

friendly and helpful,

To help people at all times,

SUPPORTING GIRL SCOUTS!

imaged. Images may be used in

considerate and caring,

And to live by the Girl Scout Law.

promotional materials, news releases,

courageous and strong, and

Learn more about Girl Scouts at

When making the GS Promise, individual members may

and other published formats for either

responsible for what I say and do,

substitute wording appropriate to their own spiritual

the local Girl Scout Councils or Girl

and to

beliefs for the word “God.”

Scouts of the USA. The images will be

respect myself and others,

ADMIN USE ONLY:

the sole property of either the local Girl

respect authority,

I accept and abide by the Girl Scout Promise and Law:

Scout Council or Girl Scouts of the USA.

use resources wisely,

Council Code:

make the world a better place, and

Service Unit/Team:

 I wish to opt out at this time.

be a sister to every Girl Scout.

Signature

Date

Group/Troop:

Return this registration form, along with GSUSA annual membership fee or applicable Lifetime fee to your local council. Fees are non-refundable or transferable to another person.