#330 Girl Financial Assistance Request

Girl Financial Assistance Request
This information is confidential and reviewed only by council staff. Only a parent or caregiver is permitted to complete and sign this form. Please note that the fulfillment process may take approximately 2–3 weeks. Please reach out with questions or concerns to customercare@gseok.org or 918-749-2551.
Girl Scout's Full Name*
Troop Number*
Years a Girl Scout*
Parent/Guardian Name*
Parent Email*
example@example.com
Address*

Address

Street Address Line 2

CityState / Province

Zip
Cell Phone*
Girl Scout Level:*

DaisyBrownieJuniorCadetteSeniorAmbassador

Total Annual Family Income (from all sources):*

Under $15,000$15,001 - $25,000$25,001-$35,000$35,001-$45,000$45,001-$55,000$55,001-$75,000Over $75,000
Number of dependent children living at home:*
Number of people supported by this income:*
List any unusual or extraordinary family expenses or circumstances (unexpected medical expenses, job loss, etc :*

Girl Scout participates in GS activities/meetings:*

All of the timeSome of the timeSeldom
Participated in most recent Girl Scout Cookie Program? (Non-participation significantly impacts amount of financial assistance granted)*

YesNo
If no, why?*
Available Cookie Credit will be applied before Financial Assistance is granted.
Girl's Virtual Cookie Card Number:
Financial Assistance is needed for (Please specify):*

Uniform Components and/or BooksCouncil Activity, Event, or CampGSUSA or Council Travel Opportunity
Council Activity, Event, or Camp*
GSUSA or Council Travel Oppertunity

A maximum of 1/2 the total cost of transportation and event fees up to a maximum of $500.00 per trip may be awarded to any girl for up to two travel opportunities - no more than one during a membership year (October-September Applicant is responsible for payment of deposits. Amount of assistance will be determined based on a calculation of need. When applying for assistance for a GSUSA Travel Opportunity, attach a copy of the selection notification letter that lists the dates of the event and the event fee. If for any reason you do not attend this event, all financial assistance and Cookie Credit must be returned to Girl Scouts of Eastern Oklahoma.
GSUSA or Council Travel Opportunity*
Cost*
Start Date

MonthDayYear
Date
End Date*

MonthDayYear
Date
Please upload copy of notification letter that lists dates and fees. *

Cancelof

Amount you can pay:*
Amount you are requesting:*
Amount of Cookie Program Credit you would like to apply:*
Have you received financial assistance from Girl Scouts of Eastern Oklahoma in the past 12 months*

YesNo
Amount received and for what purpose:
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear

If assistance is being requested for New Troop Start-Up, the following information and the signature of the troop leader is required. Check will be mailed to the troop leader
Troop Leaders Name
Email
example@example.com
Address

Address

Street Address Line 2

CityState / Province

Zip
Cell:
Date

MonthDayYear
Date

Select Preferred Delivery

Ship merchandise directly to your address.Merchandise will be picked up at the Girl Scout Store, 4810 South 129th East Avenue, Tulsa. (Merchandise will be held for 60 days maximum)
If your request is approved, $10 in troop startup funds will be sent directly to the Troop Leader by mail.
Although not required, partial or full reimbursement (when and if possible) of any funds granted is appreciated and accepted at any time by Girl Scouts of Eastern Oklahoma. This enables GSEOK to continue to provide assistance for girls when the need arises. Reimbursements and donations may be sent to: Girl Scouts of Eastern Oklahoma, Volunteer Services, 4810 South 129th East Avenue, Tulsa OK 74134.
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