Financial Assistance Request for a New GSUSA Membership

1
Are you requesting Financial Assistance for a new GSUSA Girl Membership* This field is required.Note: A new membership means she has never been a Girl Scout.
YESNO
2
Are you the primary caregiver?* This field is required.Note: If you are not the primary caregiver, please pause the questionnaire and ask the primary caregiver to complete it.
YESNO
3
How many girls in your household need financial assistance?* This field is required.Note: Girls must be enrolled in K-12 for the current school year. PreK girls may join Girl Scouts anytime after April 1.
1
2
3
4
5
6
4
First Girl's Name * This field is required.
First Name
Last Name
5
Second Girl's Name* This field is required.
First Name
Last Name
6
Third Girl's Name* This field is required.
First Name
Last Name
7
Fourth Girl's Name* This field is required.
First Name
Last Name
8
Fifth Girl's Name* This field is required.
First Name
Last Name
9
Sixth Girl's Name* This field is required.
First Name
Last Name
10
First Girl's School Grade* This field is required.What is her current grade? If it's after May 31, please select her grade for the fall semester.
Please Select
Please Select
PreK
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grades
11
Second Girl's School Grade* This field is required.What is her current grade? If it's after May 31, please select her grade for the fall semester.
Please Select
Please Select
PreK
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grades
12
Third Girl's School Grade* This field is required.What is her current grade? If it's after May 31, please select her grade for the fall semester.
Please Select
Please Select
PreK
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grades
13
Fourth Girl's School Grade* This field is required.What is her current grade? If it's after May 31, please select her grade for the fall semester.
Please Select
Please Select
PreK
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grades
14
Fifth Girl's School Grade* This field is required.What is her current grade? If it's after May 31, please select her grade for the fall semester.
Please Select
Please Select
PreK
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grades
15
Sixth Girl's School Grade* This field is required.What is her current grade? If it's after May 31, please select her grade for the fall semester.
Please Select
Please Select
PreK
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grades
16
First Girl's Participation Type* This field is required.i.e., My girl will be participating in a troop or as a Juliette (Individually Registered Girl Scout)
Troop
Juliette
I Don't Know
17
Second Girl's Participation Type* This field is required.i.e., My girl will be participating in a troop or as a Juliette (Individually Registered Girl Scout)
Troop
Juliette
I Don't Know
18
Third Girl's Participation Type* This field is required.i.e., My girl will be participating in a troop or as a Juliette (Individually Registered Girl Scout)
Troop
Juliette
I Don't Know
19
Fourth Girl's Participation Type* This field is required.i.e., My girl will be participating in a troop or as a Juliette (Individually Registered Girl Scout)
Troop
Juliette
I Don't Know
20
Fifth Girl's Participation Type* This field is required.i.e., My girl will be participating in a troop or as a Juliette (Individually Registered Girl Scout)
Troop
Juliette
I Don't Know
21
Sixth Girl's Participation Type* This field is required.i.e., My girl will be participating in a troop or as a Juliette (Individually Registered Girl Scout)
Troop
Juliette
I Don't Know
22
Are you requesting financial assistance for a new GSUSA Adult Volunteer Membership?* This field is required.If the answer is yes, you must be willing to volunteer for an existing troop, or start a new troop, or serve in a volunteer role within the service unit or council. You must be at least 18 years of age. All volunteers are required to complete an initial and annual background check. Additional adult volunteers must fill out a separate form.
YESNO
23
Adult Volunteer's Participation Type* This field is required.
Troop Leader or Co-Leader
Troop Support Volunteer
Service Unit Volunteer
Council Volunteer
24
Your Name* This field is required.
First Name
Last Name
25
Your Email Address* This field is required.
example@example.com
26
Your Physical Address* This field is required.No P.O. Boxes
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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
27
Is this the same address for your girl(s)?* This field is required.
YESNO
28
Girl(s)' Home Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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
29
Your Phone Number* This field is required.
Please enter a valid phone number.
30
Total Annual Income* This field is required.Note: Income earned by all adults in the household.
Less than $25,000
$25,001 to $35,000
$35,001 to $45,000
$45,001 to $55,000
$55,001 to $65,000
Over $65,001
31
How many people does this income support?* This field is required.
1
2
3
4
5
6
7
8 or more
32
List or explain any unusual or extraordinary family expenses or circumstances. * This field is required.Ex: unexpected medical expenses, job loss, natural disaster, single caregiver income, etc. If you do not have extenuating circumstances to list or explain, please enter not applicable or N/A
Huge
Large
Normal
Small
Ok
Ok
33
Signature* This field is required.The information provided on this form is true and accurate to the best of my knowledge.
Clear
Should be Empty: