Registrar Request for Program Credits Use

This from is to be used for Program Credits Reward requests by Camp and Event Registrars. If you’re organizing a Volunteer-Led Day or Twilight Camp, Community Camp, or Service Unit event, please fill out the information below.

This is the information that Girl Scouts of Western Washington needs so we know where we will be sending the requested funds. Please have the full card number, expiration, CVV, and mailing address ready before proceeding.

Please also double check that the card has been activated and that there are adequate funds.

To use your Program Credits on troop or group travel, or at program partner events, fill out the Caregiver Request for Program Credits Use form.

Name of Event/Destination*

Send Payment To*

Contact Name*

Contact Email*

example@example.com

Phone Number*

Girl Scout Name*

Youth First NameYouth Last Name

Is the Girl Scout using a Top Cookie Seller discount? (50% off one GSWW camp session)*

NoYes

Amount covered by the 50% discount; council will deposit this into the camp account on behalf of the Girl Scout. Council will reach out if the discount has already been redeemed.*

Is the Girl Scout using Program Credits to pay part or all of the remaining balance?*

NoYes

Before entering Program Credits information below, check with the guardian of the Girl Scout to ensure:

- Card is active

- Amount of available Program Credits is greater than or equal to amount requested

Program Credits Amount*

USD

Payment Method
Credit

Program Credits Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country