Financial Assistance Request Form - Girl Scouts Of The Missouri Heartland
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1Girl Scouts of the Missouri Heartland, Inc.
Financial Assistance Request
for events, camp, series, or travel
Please attach to Event, Camp, or Travel Registration Form. Forms must be received by the registration
deadline listed for your event. Incomplete forms will be denied.
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Request for:
Girl
Adult
Name __________________________________ Address ___________________________________
City _____________________ County _____________________ State _______ Zip ______________
Phone _____________________ E-mail _________________________________________________
Girl Scout Affiliation (check all that apply)
Program Age Level
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Girl Member Troop Number (if applicable) ___________
Girl Scout Daisy (grades K-1)
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Leader or Co-Leader of Troop Number: _____________
Girl Scout Brownie (grades 2-3)
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Registered Adult
Girl Scout Junior (grades 4-5)
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Service Team Member for Service Unit Number:______
Girl Scout Cadette (grades 6-8)
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Position: _______________________________________
Girl Scout Senior (grades 9-10)
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Facilitator
Girl Scout Ambassador (grades 11-12)
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Other:________________________________________
Assistance Type
Amount Required/Fees
Amount Requested
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Council Event/Series/Travel
$ __________
$ __________
Name of Event/Series/Travel: _____________________
Date of Activity:________________
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Summer Camp
$ __________
$ __________
Location of Summer Camp: ______________________
Date of Camp Session:__________
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National destination
$ __________
$ __________
destination Location: ____________________________
Date of destination Travel: _______
Girl Scout Participation
Number of years as a Girl Scout: ________ Number of years in this troop (if applicable): ___________
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Fall Product Program
Girl Scout Cookie Program
Reason(s) for Financial Need
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Annual Household Income:
$0 - $20,000
$20,001 - $30,000
$30,001 - $40,000
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$40,001 - $50,000
$50,001 - $60,000
$60,001 and up
Number of Household Members: ____________ Other pertinent information: ____________________
__________________________________________________________________________________
__________________________________________________________________________________
Requestor Information
Name ___________________________ Relationship to individual listed above ___________________
Daytime Phone Number _______________________ E-mail__________________________________
It is our goal that no girl be turned away due to a financial need. We receive many requests for assistance throughout the
entire year. If you can pay a portion of the fee, please enclose that portion with your request, so our funding can benefit girls
throughout the entire year.
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For Office Use Only: Approved
Denied
Reason for Denial ____________________________________
Amount Approved $ ________ Date Approved _________ RM _________ GL ________
Dept ______________
Reg’d _________________________ LLS ________________________________________________________
Girl Scouts of the Missouri Heartland, Inc.
T 877-312-4764 ● F 417-862-4120 ● ●
P:\GSMOHEARTLAND DATA\Forms\Financial Assistance 10/29/12
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