Membership Registration Form

Sign-up for the most epic year yet, become a Girl Scout!

Just a little information is all we need to get your new membership completed or renew your current membership.
Adult Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you joining for for the first time or renewing for another year of fun

1st time! Renew me now!
Birthdate

Month Day Year
Why do we ask? If you volunteer or help with the troop this is needed to get you started with your background screening.
Would you like us to text you regarding exciting participation information? *

Yes No
Are you also registering or renewing a girl today?

Yes No
How would you like to participate as a member?
Do you have the Simply Healthcare Florida Healthy Kids plan? ***Simply Healthcare plan members with a Florida Healthy Kids plan can choose to receive a free girl membership valid Oct 1 2020 - Sept 30 2021.*

Yes No
Is your girl/s with the Florida Healthy Kids plan who is receiving the free membership already a member for 2021 which started on October 1, 2020? ***Current members who already purchased a 2021 membership will receive a 2nd year of membership for free valid Oct 1 2021 - Sept 30 2022***

Yes No
Upload a copy of your girl's Simply Healthcare plan card for verification.

Browse Files

Cancel of
Girl #1 Name *

First Name Last Name
Girl #1 Birthdate *

Month Day Year
This is required to place her in the appropriate age level program.
Girl #1 Grade as of Fall 2020. *
Let us know which ways your girl/s would like to participate: *

I would like to start an in-person troop with my girl. I would like to find an in-person troop my girl can join. My girl would like to participate as an individual member. I would like to join a virtual troop. I'm not sure, please contact me.
Do you have a specific troop for Girl #1 to join? *

Yes No
Troop #
Girl #2 Name

First Name Last Name
Girl #2 Birthdate

Month Day Year
This is required to place her in the appropriate age level program.
Girl #2 Grade as of Fall 2020.
Let us know which ways your girl/s would like to participate:

I would like to start an in-person troop with my girl. I would like to find an in-person troop my girl can join. My girl would like to participate as an individual member. I would like to join a virtual troop. I'm not sure, please contact me.
Do you have a specific troop for Girl #2 to join?

Yes No
Troop #
Girl #3 Name

First Name Last Name
Girl #3 Birthdate

Month Day Year
This is required to place her in the appropriate age level program.
Girl #3 Grade as of Fall 2020.
Let us know which ways your girl/s would like to participate:

I would like to start an in-person troop with my girl. I would like to find an in-person troop my girl can join. My girl would like to participate as an individual member. I would like to join a virtual troop. I'm not sure, please contact me.
Do you have a specific troop for Girl #3 to join?

Yes No
Troop #

Membership Products

Girl Membership - Oct 1 2020 thru Sept 30 2021.

$ 25.00 Quantity

Adult Membership - Oct 1 2020 thru Sept 30 2021.

$ 25.00 Quantity

Simpy Healthcare Girl Membership - Oct 1 2020 thru Sept 30 2021. This is only available for Simply Healthcare plan participants who have a Florida Healthy Kids plan and is limited to girl memberships only. Each girl requesting a free membership must submit a copy of the Simply Healthcare plan card to be eligible.

Free Quantity

Total

$ 0.00

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

Sign-up for the most epic year yet, become a Girl Scout!