Uniform and/or Financial Assistance for Youth Members

Uniform and/or Financial Assistance for Youth Members

Use this form to request assistance in purchasing a uniform, uniform components such as pins, badges, patches, program resources, and/or help towards paying troop dues and trip/event costs. You must submit one form per each member you are requesting for. Submit six (6) weeks in advance of need as requests may take up to 6 weeks for review and processing.
Girl Information
Name*

First NameLast Name
Grade*
Date of Birth*

MonthDayYear
Date
Did this member participate in council product sales? (Treats & Reads and/or Cookies)*

YesNo
If no, why?*
Family Information
Parent/Guardian #1 Name*

First NameLast Name
Parent/Guardian #1 Email*
example@example.com
Parent/Guardian #1 Phone Number*
Please enter a valid phone number.
Parent/Guardian #1 Employer*
Parent/Guardian #1 Occupation*
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Phone Number
Please enter a valid phone number.
Parent/Guardian #2 Employer
Parent/Guardian #2 Occupation
# of children (under 18) in household*
Age(s) of children in years (please separate with comma)*
# of other dependents in household*
Do you receive any of the following (select all that apply)*

AFDCSSISocial SecurityHousing SubsidySubsidized MealsNone of the aboveOther
Gross Family Income (select one)*

$0-$24,999$25,000-$34,999$35,000-$44,999$45,000-$54,999$55,000-$64,999$65,000-$74,999$75,000 & above
From the list below, select all the expenses which affect your financial needs (checkmark all that apply)*

Medical/DentalLegalEducationDebtSingle IncomeJob LossDisabilityOther
Please explain any unusual situations or expenses that should be taken under consideration.
Troop Information
Troop Co-Leader Name*

First NameLast Name
Troop Co-Leader Phone*
Please enter a valid phone number.
Troop Co-Leader Email*
example@example.com
Troop Number*
Juliettes please enter 00000
Service Unit*
Select "I don't know" at bottom of list to enter town.
What town does the troop meet in?*
Has the troop submitted the council ACH form for this membership year?*

YesNoUnsure
Please submit an ACH form immediately following this form submission.
Troop Dues Request

Max allowance for troops to collect per youth member is $25 per year.
Are you requesting funds to cover Troop Dues?*

YesNo
Troop Dues ($ amount per youth member per year)*
Max allowance for troops to collect per youth member is $25 per year.
Total amount of Troop Dues family can pay*
Auto-calculated: Total amount requested for Troop Dues Assistance
This field will auto-calculate a total.
Uniform Component & Program Resource Request
What level do you need components for?*
Select Daisy Tunic or Vest*

TunicVestNot needed
Please Select Brownie Sash Size*

RegularLongNot needed
Please Select Junior Sash Size*

RegularLongNot needed
Please Select Cadette/Senior/Ambassador Sash Size*

RegularLongNot needed
Wavy Flag*

YesNo
Council ID Set*

YesNo
Troop Numerals*

YesNo
Please provide troop number*
Insignia Tab*

YesNo
WAGGGS Pin*

YesNo
Crest*

YesNo
Membership Pin*

YesNo
Petals/Badges/Journey Books or Awards Requested
Event/Trip/Training Request
Are you requesting assistance for a Program Event/Trip/Training?*

YesNo
Thank you for filling out this form. Please submit!
Event Name*
Event Location*
Event Date*

MonthDayYear
Date
Total Event Cost per member*
Amount Paid from other sources*
Amount Requesting*
Request for a second event?*

YesNo
Event Name*
Event Location*
Event Date*

MonthDayYear
Date
Total Event Cost per member*
Amount Paid from other sources*
Amount Requesting*
Thank you for filling out this form. Please submit!
Should be Empty:

Uniform and/or Financial Assistance for Youth Members

Girl Information

Family Information

Troop Information

Please submit an ACH form immediately following this form submission.

Troop Dues Request

Uniform Component & Program Resource Request

Event/Trip/Training Request

Thank you for filling out this form. Please submit!

Thank you for filling out this form. Please submit!