Girl Scouts of Kansas Heartland Campership Form

CAMPERSHIP GUIDELINES:

Camperships are granted only to current girl members registered with Girl Scouts of Kansas Heartland.
Camperships are granted based on the financial need and availability of funds, with priority given to first-time applicants.
Camperships are not designed to replace program credits earned by Girl Scouts, but can supplement additional need; program credits will be applied to registration fees prior to campership funds.
Camperships may be requested for part or the entire program registration fee and may be approved in whole, in part, or denied.
This form must be completed by the parents/guardians.
Campership applications for events or summer programs must be submitted at least four weeks prior to the event.
***Do not pay in advance for program registration fee and then request a refund.****
Incomplete applications will be returned to the parent/guardian and will need to be resubmitted for consideration.
Please allow one to two weeks for a reply and please provide your preferred method of communication below.
If requesting assistance for more than one program, event, or camp, a separate form must be submitted for each event.

GIRL/FAMILY FINANCIAL INFORMATION: Program Age-Level (Check one of the following):*

Girl Name: *

First NameLast Name

Girl Date of Birth: *

Date

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

First NameLast Name

Phone Number: *

Area CodePhone Number

Email: *

Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

County of Residence: *

Preferred method of communication for council response:

Occupation of Parent(s) or Guardian(s): *

Annual Household Income Level:*

Number of Dependents in Household: *

Number of Adults in Household: *

Did your daughter participate in the previous Fall Product Program (nuts & candy sales)?:*

YesNo

Did your daughter participate in the previous cookie sale?:*

YesNo

Are there extenuating circumstances that affect your income?:

Program Name: *

Date(s) of Program:*

Program Location:*

Program Registration fee:*

Program Credits to be applied:*

Amount to be paid by family:*

Campership Amount Requested:*

Are you requesting transportation assistance? If yes, please select your preferred gas station:

No, transportation assistance is not requestedYes, Quik TripYes, Kwik ShopYes, Kroger/Dillons

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 towards camps and events.

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 Campership application approval is not contingent on KanCare funding.

Is the Girl Scout requesting this campership a KanCare recipient?:*

YesNo

KanCare Provider:*

Sunflower Health PlanUnited HealthcareHealthy Blue

9-digit KanCare ID#:*

Parent(s)/Guardian Signature:*

First NameLast Name

Date:*

MonthDayYear

Campership Application

Please provide information below regarding the program experience for which assistance is being requested, and sign and date form.

Funds can also be requested to assist with transportation costs, which is provided in the form of a gas gift card.

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