GSNYPENN Updated Financial Assistance Form

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Financial Assistance Application is for:* This field is required.To Be Filled Out By Parent/Guardian This application is NOT required for financial assistance requests for Girl Membership fees. If you would like financial assistance for a Girl Membership please email info@gsnypenn.org.
Adult Membership
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County Applicant Lives:* This field is required.ATTN Delaware County Residents: Thanks to the generosity of the A. Lindsay & Olive B. O'Connor Foundation, Inc., registered Girl Scouts, soon-to-be Girl Scouts that attend South Kortright Central School, Beyond program youth and/or live in Delaware County can attend one of GSNYPENN's camps at no cost while funding is available. As a not-for-profit, we must have the application on file for any funding awarded.
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Allegany
Bradford
Broome
Cayuga
Chemung
Chenango
Cortland
Delaware
Herkimer
Jefferson
Lewis
Madison
Oneida
Onondaga
Ontario
Oswego
Otsego
St. Lawrence
Schuyler
Seneca
Steuben
Tioga, PA
Tioga, NY
Tompkins
Wayne
Yates
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Email* This field is required.
example@example.com
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Applicant Name* This field is required.
First Name
Last Name
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* This field is required.
Troop Number
Service Unit
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What will be your role in the Troop?* This field is required.
(Co-leader, Cookie Coordinator, Troop Treasurer, etc)
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Date * Date of Birth
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Phone Number* This field is required.
Please enter a valid phone number.
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Select ALL Household income sources that apply:* This field is required.
Salaries/wages
Disability
Child Support
Social Security
Unemployment
Food Stamps (EBT)
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What is the household's ANNUAL gross income? Include all above income sources in total:* This field is required.
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How much can you contribute toward your request?* This field is required.Adult Membership is $25 for MY25.
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Financial assistance is awarded on a sliding scale based on family income and size. If there are any other circumstances that we should consider when reviewing your application, please explain here.Assistance is not guaranteed for all applicants.
Huge
Large
Normal
Small
Ok
Ok
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Total number of Adults in your household:* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8+
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Total number of children in your household:* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8+
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Submit your completed Financial Assistance Application with the following : Current year’s Federal tax Return OR Copies of the last two paycheck stubs for all working individuals in household or a letter from employer stating your annual salary. Copies of any supporting documentation listed in the above household income sources line. Please mark out all social security numbers, tax ID numbers and/or credit card numbers before submitting any paperwork. Documents can be emailed to advancement@gsnypenn.org as well. Please send information along so your application can be processed in a timely manner.
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Applicant Agreement* This field is required.I certify that this information is true and complete to the best of my knowledge. I grant permission to the Girl Scouts of NYPENN Pathways to verify this information. I agree to notify the Girl Scouts of NYPENN Pathways if my financial status should change.
YESNO
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Submission Date
Date
Year
Month
Day
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