Event Financial Assistance for Youth Members-NOT FOR SUMMER CAMP
Use this form to request assistance in troop and council trip/event costs. You must submit one form per member you are requesting assistance for. Submit six (6) weeks in advance of need as requests may take up to 6 weeks for review and processing.
Youth Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Troop Number
*
Juliettes please enter 00000
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Next
Family Information
Parent/Guardian #1 Name
*
First Name
Last Name
Parent/Guardian #1 Email
*
example@example.com
Parent/Guardian #1 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.
*
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Are you requesting funds to cover Troop or Girl Scout of Connecticut Event?
*
Troop
Girl Scouts of Connecticut Sponsored
Service Unit
Name of Event:
*
Date of Event:
*
-
Month
-
Day
Year
Date
Registration Cost:
*
Total Cost of Event for Youth
Amount Family Can Pay
*
Financial Aid Requested:
Thank you for filling out this form. Please submit!
Submit
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