Pixie Plus Application

Application

Organization Information

Organization Name *

Contact person *

Address *

Address 2

City *

State *

Zip Code *

Organization phone number *

Contact phone number *

e-mail *

Organization Website *

Non-profit organization? *

Yes No

Has your organization been previously approved as a Program Partner with GSNEO? *

Yes No

We have included a certificate of liability insurance that our organization has at least $1,000,000 in general liability with this application.

Certificate of Liability Insurance *

Upload a File

Service provider agrees to provide a Certificate of Liability Insurance naming GSNEO as an additional insured.

Organizational Description

What will girls who participate in your program do? *

Program Grade Level (check all that apply) *

Daisy (K-1) Brownie (2-3) Junior (4-5) Cadette (6-8) Senior (9-10) Ambassador (11-12)

Safety & Risk Management

By completing this application, the organization verifies that it supports the Girl Scout mission and value statements. Please read each item and your digital signature below verifies that your organization meets our criteria:

Our organization supports Girl Scouts in its efforts to make Girl Scouting available to all girls and adults.
We have read, understand, and comply with all the safety guidelines and Safety-Activity Checkpoints.
We understand that alcohol is not permitted at events offered exclusively for Girl Scouts.

Mutual Indemnification

The Girl Scouts of North East Ohio and the Vendor, (vendor name)

hereby agree to indemnify and hold harmless each other as well as their respective Board of Directors, all their officers, agents, legal representatives, employees, successors and assigns, from and against any and all losses, liabilities, damages, demands, expenses or causes of actions (whether negligent or intentional), which either may incur based upon a breach of any term or condition of this Agreement.

Handouts & Promotional Material

Please attach copies of all handouts and promotional material that will be delivered to Girl Scouts.

Handouts

Upload a File

Promotional material

Upload a File

By writing or typing your name, you are stating that all the information in this application is correct, to the best of your knowledge. Your typed name serves as a digital signature. An application without a name on this line will not be considered.

Organization Name *

Representative Name *

Today's Date

Month Day Year

Pixie Plus Annual Subscription

Pixie Plus Annual Subscription $ 100.00

Total $ 0.00

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Thank you for your desire to partner with GSNEO. Please allow 2-3 weeks for processing and review. You will be notified upon acceptance. A completed application is not guarantee of membership.

GSNEO reserves the right to deny partnership requests or remove program listings for any reason.