Girl Scouts Membership Form

Girl Membership

Girl Scouting builds girls of courage, confidence, and character, who make the world a better place.

Join the global network of 2.7 million Girl Scouts.

Membership Year through 9/30/2018

* Denotes Required Fields

For Admin Use Only

Troop Number

Service Unit

Girl First Name

*

Middle

Last

*

Address

*

Apartment

City

*

State

*

Zip Code

*

(

)

(

)

Home Phone

Cell Phone (if 13 and older)

E-Mail Address (if 13 or older)

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 is reported separately. This information is used for statistical purposes only.

Date of Birth*: (mm/dd/yyyy)

/

/

School Grade in Fall 2017*:

# of Years as a Girl Scout:

Custodial Care*: (mark one)

o Both Parents

o Mother/Guardian Only

o Father/Guardian Only

o Other

Name of School:

Race: (mark all that apply) o American Indian or Alaskan Native

o White

Hispanic or Latina:

o Asian

o Other (please specify)

o Yes

o Black or African American

o I choose not to share at this time

o No

o Hawaiian or Pacific Islander

o I choose not to share at this time

Parent/Guardian First Name

*

Middle

Last

*

Address – check here if address is same as girl: o

Apartment

City

State

Zip Code

(

)

(

)

Home Phone

Cell Phone

E-Mail Address

*

Job Title

Employer

Parent/Guardian Signature Required

The Girl Scout Promise

•

I acknowledge that the registrant will accept and abide by the Girl Scout Promise and Law (at left) and has permission to join the

On my honor, I will try:

Girl Scouts.

To serve God and my country,

•

When participating in Girl Scout activities I give consent for the registrant to be photographed for print, videotaped, or electronically

To help people at all times,

imaged. Images may be used in promotional materials, news releases, and other published formats for either the Girl Scouts of

And to live by the Girl Scout Law.

Greater New York or Girl Scouts of the USA. The images will be the sole property of either the local Girl Scout Council or Girl Scouts

of the USA.

When making the GS Promise, individual members

may substitute wording appropriate to their

o

I wish to opt out of media opportunities at this time.

own spiritual beliefs for the word “God.”

The Girl Scout Law

Signature of Parent/Guardian

Date

I will do my best to be

Family

Share Girl Scouting with more girls

honest and fair,

Your family’s donation to the Girl Scouts of Greater New York’s Family Partnership program

Partnership

friendly and helpful,

helps us serve girls in NYC, and supports the high quality programs your Girl Scout enjoys.

considerate and caring,

Your gift can make a real difference in a girl’s life. Donate today!

courageous and strong, and

Donations of $25 or more, per member, receive a limited edition patch.

responsible for what I say and do,

and to

+

=

Membership Fee:

Family Partnership Donation:

Total Attached:

Payment Method:

respect myself and others,

$25

o $500

o $50

o Cash

o Amex

respect authority,

$

o $250

o $25

o payable to

o Discover

use resources wisely,

o $100

o Other:

Girl Scouts

o Mastercard

make the world a better place, and

o Visa

be a sister to every Girl Scout.

Name on Credit Card

Address of Credit Card Holder

Thank you

City of Credit Card Holder

State

Zip Code

for joining

Girl Scouts!

Credit Card Number

Exp. Date

CCV#

Signature of Credit Card Holder

Today’s Date

Fees are non-refundable or transferable to another person. Membership fees and donations paid by credit card will be charged separately.