GSMW Financial Assistance Request

Fall and Cookie Program Experience

Participation in the Cookie Program and Fall Program is essential because it gives girls an opportunity to help themselves.
Participated in the Cookie Program?*

YesNo
If Yes, # of Boxes Sold
Example: 225
Participated in the Fall Program?*

YesNo
If Yes, $$ Sold
Example: $900

Household Information
Girl Currently Lives With*

Both ParentsMotherFatherGuardianOther
Parent / Guardian Name*

First NameLast Name
Parent / Guardian Email Address*
Date of Birth*

MonthDayYear
Date
Parent / Guardian Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County*
Primary Phone*

Area CodePhone Number
Phone type*
Secondary Phone

Area CodePhone Number
Phone type
Mother Occupation
Father Occupation
Guardian Occupation
Occupation
# of Dependent Children in Household*
Age(s) of Dependent Children
# of Dependent Children Living Outside of Household*
Ages of Other Dependents
Do you qualify for state/federal financial assistance (ie. free/reduced lunch, food stamps)?*

YesNo
Income Verification Upload

Upload a File

Cancelof

Parent / Guardian 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