GIRL SCOUTS OF KANSAS HEARTLAND: COUNCIL CARES

COUNCIL CARES UNIFORM APPLICATION

Our Council Cares program offers girls the opportunity to participate in Girl Scouting. Council Cares may be awarded to a currently registered Girl Scout to purchase a uniform (tunic or sash), uniform components (troop numerals, council ID set, flag set), and/or a Journey book (if the troop will be completing a journey together).
Council Cares Uniform Guidelines:

Please be sure to read the guidelines carefully.
- Council Cares awards are granted only to current girl members registered with Girl Scouts of Kansas Heartland.
- Council Cares awards are granted based on the financial need
  and availability of funds, with priority given to first-time applicants.
- Council Cares awards are not designed to replace program credits
  earned by Girl Scouts, but can supplement additional need; program credits will be applied to uniform costs prior to council cares funds.
- Council Cares awards may be requested for part or the entire amount needed and may be approved in whole, in part or denied.
- This form must be completed by the parent/guardian.
- ***Do not pay in advance for uniform items or Journey book and then request a refund.***
- Incomplete applications will be returned to the parent/guardian and will need to be resubmitted for consideration.
Please allow 5-7 business days for a reply by email.
Girl Name:*

First NameLast Name
Girl Date of Birth: *

MonthDayYear
Name of Parent(s) or Guardian(s):*

First NameLast Name
Phone Number:*

Area CodePhone Number
Email:*
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County of Residence: *
Occupation of Parent(s) or Guardian(s):*
Annual Household Income Level:*
Number of Dependents in Household:*
Number of Adults in Household:*
Number of girls in Girl Scouts:*
Did your daughter participate in the previous Fall Product Program?*

YesNo
Did your daughter participate in the previous Cookie Program?*

YesNo
Are there extenuating circumstanes that affect your income?
Program Age-Level (Check one of the following):*

Daisy (Grades K-1)Brownie (Grades 2-3)Junior (Grades 4-5)Cadette (Grades 6-8)Senior (Grades 9-10)Ambassador (Grades 11-12)
Check all items for which assistance is being requested, and sign and date the form.*

Uniform- Tunic for Daisies and Sash for all other levelsTroop NumbersCouncil ID SetFlagInsigniaMembership PinJourney Book (if troop will be completing together, obtain book title from Troop Leader)
Tunic Size*
Sash Size*

RegularX-Long
Notes: (Please indicate here if you would like to pay the difference in price to upgrade to a vest and the vest size you would like.)
If your council cares application is approved, would you like your uniform shipped to the address above?*

No, I prefer to shop in person at one of the council stores in Wichita or HaysYes, ship it to me - Allow 5-7 business days for processing. Shipping only available to customers OUTSIDE of Sedgwick and Ellis counties.
Girl Scouts of Kansas Heartland is partnered with the KanCare program. If you're currently a recipient of one of the KanCare providers (Healthy Blue, Sunflower Health Plan, United Healthcare), you may be eligible to utilize your KanCare dollars to purchase uniforms.
- You can utilize $50 per calendar year for Sunflower Health Plan and United Healthcare, or up to $75 for Healthy Blue.
- This form must be completed in its entirety.
- For Sunflower and United Health Care, the council will submit to your insurance provider on your behalf. For Healthy Blue, you will need to request a gift card for your funds - more information here: https://www.healthybluekansas.com/medicaid/extras
- Your Council Cares application approval is not contingent on KanCare funding.
Is the Girl Scout requesting the council cares a KanCare recipient?**

YesNo
KanCare Provider:*

Sunflower Health PlanUnited HealthcareHealthy Blue
9-digit KanCare ID#: *
Parent/Guardian Signature*

First NameLast Name
Date*

MonthDayYear
Date
Please allow 5-7 business days for a reply via email.
Council Cares awards help girls enjoy the benefits of Girl Scouting.The Council appreciates and welcomes donations designated for the GSKH Council Cares Fund.
Should be Empty:

COUNCIL CARES UNIFORM APPLICATION

Please allow 5-7 business days for a reply via email.

Council Cares awards help girls enjoy the benefits of Girl Scouting.The Council appreciates and welcomes donations designated for the GSKH Council Cares Fund.