Uniform and/or Financial Assistance for Youth Members
Use this form to request assistance in purchasing a uniform, uniform components, 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
Check out this website for an Essentials Guide to your youths uniform!
https://www.flipsnack.com/95EB8A5569B/2023-essentials-guide/full-view.html
Youth Information
Name
*
First Name
Last Name
Grade
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Date of Birth
*
-
Month
-
Day
Year
Date
Family Information
Parent/Guardian #1 Name
*
First Name
Last 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 Name
Last 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)
*
AFDC
SSI
Social Security
Housing Subsidy
Subsidized Meals
None of the above
Other
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/Dental
Legal
Education
Debt
Single Income
Job Loss
Disability
Other
Please explain any unusual situations or expenses that should be taken under consideration.
Troop Information
Troop Number
*
Juliettes please enter 00000
What town does the troop meet in?
*
Troop Dues Request
Max allowance for troops to collect per youth member is $25 per year.
Are you requesting funds to cover Troop Dues?
*
Yes
No
Troop Dues ($ 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.
Service Unit and/or Troop Event/Trip Request
Are you requesting assistance for a Service Unit and/or Troop Event/Trip?
*
Yes
No
Event Name
*
Event Location
*
Event Date
*
-
Month
-
Day
Year
Date
Total Event Cost per member
*
Amount Paid from other sources
*
Amount Requesting
*
Request for a second event?
*
Yes
No
Event Name
*
Event Location
*
Event Date
*
-
Month
-
Day
Year
Date
Total Event Cost per member
*
Amount Paid from other sources
*
Amount Requesting
*
Uniform Component & Program Resource Request
What level do you need components for?
*
Please Select
Daisy (K & 1st grade)
Brownie (2nd & 3rd grade)
Junior (4th & 5th grade)
Cadette/Senior/Ambassador (6th grade & above)
None
Select Daisy Tunic or Vest
*
Tunic
Vest
Not needed
Select Brownie Sash or Vest
*
Sash
Vest
Not needed
Select Junior Sash or Vest
*
Sash
Vest
Not needed
Select Cadette/Senior/Ambassador Sash or Vest
*
Sash
Vest
Not needed
Wavy Flag
*
Yes
No
Council ID Set
*
Yes
No
Troop Numerals
*
Yes
No
Please provide troop number
*
Insignia Tab
*
Yes
No
WAGGGS Pin
*
Yes
No
Crest
*
Yes
No
Membership Pin
*
Yes
No
What shop will you pick up your items:
*
Hartford Shop: 340 Washington St Hartford, CT * Tuesday: 9:00 a.m.-4:00 p.m. Wednesday: 9:00 a.m.-4:00 p.m Friday: 9:00 a.m.-4:00 p.m. *Phone: (800)922-2770 x3240 *Email: hfshop@gsofct.org
North Haven Shop: 20 Washington Ave, North Haven, CT * Tuesday: 10:00 a.m.-4:00 p.m. Wednesday: 10:00 a.m. - 4:00 p.m. Thursday: 1:00 p.m.-7:00 p.m. Friday: 10:00 a.m. - 4:00 p.m. Saturday: 10:00 a.m. - 2:00 p.m. *Phone: (800)922-2770 x3330 *Email: shop@gsofct.org
Lebanon Shop: 175 Clubhouse Rd Lebanon, CT * Thursday: 4:00 p.m.-8:00 p.m. Saturdays: 9:00 a.m.– 1:00 p.m. *Phone: (800)922-2770x3730 *Email: lstore@gsofct.org
Stamford Shop: 69 Guinea Rd Stamford, CT * Wednesday: 10:00 a.m.–4:00 p.m. Thursday: 10:00 a.m.–5:00 p.m. Friday: 10:00 a.m.–5:00 p.m. *Phone: (800)922-2770x3818 *Email: wstore@gsofct.org
If these location do not work, we can ship at your cost. Choose this option and a shop employee will be intouch!
Thank you for filling out this form. Please submit!
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