FA ALT REG FORM

Adult Financial Assistance Registration

Use this form to request Adult financial assistance for the annual membership fee. Girl Scout Memberships are Valid 10/1 through 9/30. Please select the membership year below (2021-2022 or 2022-2023).
Membership Status *

New Member Returning Member
Membership Year *

2023 Membership (valid 10/1/2022 through 09/30/2023)
Troop Number (if applicable)
Alternate Payment Options *
For Care Source members, please provide the Member Number.
Please attach a clear photo/scan of your membership card
Are you currently volunteering or do you intend to volunteer with the Girl Scouts? If so, please provide your Troop Number and your Volunteer Role.
Volunteering Troop Number
Volunteering Role *
If you are seeking general financial assistance to be paid by Girl Scouts of Greater Atlanta, please provide the following:
I am able to pay a portion of the annual membership fee, to be mailed to Council, in the amount of
I am unable to pay any portion of the annual membership fee due to:
Name *

First Name Last Name
Date of birth *

Month Day Year
Race (Check all that apply) *

Am. Indian or Alaskan Native Asian Black or African American Hawaiian or Pacific Islander White Other Races I Choose Not to Share
Ethnicity *

Hispanic Non-Hispanic I Choose Not to Share
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
County *
Primary Phone Number *

Area Code Phone Number
E-mail *
I wish to opt out of text messaging at this time.
I wish to opt out of receiving email messages from Girl Scouts of Greater Atlanta at this time.
Membership Registration Acceptance for Household
I will accept and abide by the Girl Scout Promise and Law. *

Yes, I will.
When participating in Girl Scout activities, I am be photographed for print, videotaped, or electronically displayed. My images may be used for promotional materials, new releases or other published formats by Girl Scouts of Greater Atlanta or Girl Scouts of the USA. The images will be the sole property of Girl Scouts of Greater Atlanta or Girl Scouts of the USA.

I wish to opt out of being photographed at this time.
Should be Empty:

Adult Financial Assistance Registration

Membership Registration Acceptance for Household