Program Financial Assistance Request

Caregiver Information
Girl Currently Lives With

Other
Caregiver Name

First NameLast Name
Caregiver Email Address
example@example.com
Primary Phone
Format: (000) 000-0000.
Caregiver Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Household Information
Caregiver Occupation
# Dependent Children in Household
Age(s) of Dependent Children
# Dependent Children out of Household
Ages of Other Dependents
Do you qualify for state/federal financial assistance (ie. free/reduced lunch, SNAP)?
Income Verification Upload

Cancelof

Program Information
Program Name
Program Town
Program Date
Program Cost
Special Needs (e.g. wheelchair, food allergies, inhaler, epi pen, etc.)
PARENT PERMISSIONS: Please authorize by clicking the check boxes below. If you do not authorized, please leave the checkbox blank.

Caregiver Statement

Please explain the need for financial assistance, which may include information about medical expenses, education expenses, disaster, family situation, and/or emotional need.
I am applying for Financial Assistance from GSMW because...
Additional comments/questions?
Should be Empty:

Girl Information