Financial Aid Form - Membership - 2015-2016
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1
2FINANCIAL AID FORM MEMBERSHIP YEAR 2015-2016
Complete applications accepted through 7/31/16 for membership and 4/30/16 for troop dues and shop certificates.
See complete information regarding financial aid on reverse side. Complete one financial aid form per person and attach it to the
appropriate girl or adult membership registration form along with required proof of income. If this form is incomplete it will be returned!
Girl
Adult (may apply for $15 Membership Dues only)
Proof of Income Attached (required, check ALL that apply)
Name ____________________________________________________
Salaries/Wages
Social Security
Child Support
Unemployment Comp
Disability
Worker Compensation
Address _________________________________________________
Eligible for Free and Reduced Lunch Program
SNAP Benefits Statement
City ______________________________ Zip ____________________
Troop Number____________________ Girl’s Grade ______________
Mandatory Email Address _________________________________
Daisy
Junior
Senior
Parent/Guardians’ Name ____________________________________
Brownie
Cadette
Ambassador
Contact Phone Number ___________________________________________________
Service Unit_____________________ County ___________________
____________________________
Troop Leader _____________________________________________
GSEP retail location where I will pick up shop certificate
FINANCIAL AID REQUESTED
Berks Delco Lehigh Valley Seltzer Shelly Ridge Valley Forge
GS-USA Membership Dues ($15)
Yes
No
Did your child participate in the most recent product sales (either
If “Yes”
attach application to registration form according to instructions.
cookies or Nuts About Reading)?
Yes
No
If “No” please visit our website and complete your
Total Number of People in Household
registration on-line.
2
3
4
5
6
7
8
9
10+
Troop Dues Requested (up to $25, n/a for adults or girls not
Total Annual Household Income ( include income from all sources
participating in a troop) $ _______
unemployment, support, allowances/assistance, etc.):
Below 10,000
30,001-40,000
60,001-70,000
Shop Certificate Requested (n/a for adults) for:
Journey Book
10,001 – 20,000
40,001-50,000
70,001-80,000
20,001 – 30,000
50,001-60,000
80,001 +
Uniform Components Choose only One and Select Size:
Tunic (Daisy)
Size:
S,M
L,XL
Please indicate all sources of Income:
Sash (B,J,C,S,A) Size:
Regular
X-Long
Salaries
Disability
Social Security
Other _______________________________________________
Vest (Daisy)
Size:
XXS,XS,S,M
Plus
(Brownie) Size:
S,M,L
Plus
Signature of person submitting form:
(Junior)
Size:
M,L,XL
Plus
I certify that all information on this application is true and accurate.
(C,S,A)
Size:
S,M,L,XL
Plus
________________________________________ Date ____________
GS Insignia Choose All Needed:
Council ID
Flag Patch
Troop #s (How many?) _____________ (Maximum of 5)
04/14
FOR OFFICE USE ONLY
GSUSA DUES
GSUSA Dues Awarded
Date App Received
Shop Certificate Awarded
Date Registered
Troop Dues Awarded
F A S H O P
PT
Total Awarded
F A T D
%
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Parent category: Business