Uniform Financial Assistance Application

Uniform Financial Assistance Application
To be eligible for uniform assistance, girls must agree to participate in the council sponsored product sales, be a currently registered Girl Scout (membership assistance is available), and meet financial criteria that is listed below. You will be notified of approval or denial.
Girl Full Name*

First NameLast Name
Girl Date of Birth*

MonthDayYear
Date
Girl is a WellCare Recipient.*

YesNo
School Attending*
Girl Scout Level*

Daisy (K-1)Brownie (2-3)Junior (4-5)Cadette (6-8)Senior (9-10)Ambassador (11-12)
Number of Years as a Girl Scout
Parent/Guardian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Adults Living in Home*
Number of Children Living in Home*
Financial Information

Income verification is requested to demonstrate financial need.
Household Income*

$11,999 & Under$12,000 - $15,999$16,000 - $19,999$20,000 - $24,999$25,000 - $29,000$30,000 - $34,999$35,000 - $39,999$40,000 - $49,999$50,000 - $59,000$60,000 - $69,999$70,000+
Do you have Wellcare?

YesNo
Please explain and special circumstances and/or reasons for requesting uniform assistance.
Please upload income verification. Examples of accepted items are: Medical Card, EBT Card, Unemployment Paperwork, Public Housing, etc. We do NOT recommend paystubs. *

Cancelof
Uniform Pieces Request

Items included are the Daisy Tunic or Sash for Brownie-Ambassador. The American Flag Patch, Council Identification Set, and 4 Troop Numbers,

If a vest is desired, families are responsible for paying the difference of cost between sash and vest.
Uniform Piece Desired*

Daisy TunicBrownie SashJunior SashCadette SashSenior SashAmbassador SashVest (at an additional cost - between $13-$16 depending on the level)
If you ordered a sash, what size would you need:

Regular LengthX-Large Length
If you ordered a vest, families are responsible for paying the difference between the sash or a vest (approx. $13-$16 depending on the level.) Please indicate below what size you would need.

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What troop numbers are needed?*
Has/will your girl be participating in the Fall Product or Cookie Program?*

YesNo
I am applying for Girl Membership finance assistance.*

YesNo
I am applying for Adult Membership financial assistance.*

YesNo
Today's Date*

MonthDayYear
Date
By signing my name below, I am verifying that the above information is accurate to the best of my knowledge.*

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