Adult Financial Assistance Program Application Form - 2016-2017
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1
22016-17 Adult Financial Assistance
Program Application
(ALL INFORMATION IS CONFIDENTIAL)
Directions: Please complete this application and return to the service center within 10 days of
receipt.
Please Note: Annual membership registration will be granted immediately during the registration
process. All other requests will be processed within a month of receipt of application. Individual
$100.00
grants are limited to
per program year.
PART I: ADULT INFORMATION
Adult Name ______________________________________ Phone # ____________________________
Volunteer Position: Troop Leader _____ Assistant Troop Leader _____ Chaperone Designee _____
Address ______________________________Town_______________________ Zip_______________
Troop # _____________
Region __________________________________
Leader’s Name____________________________________ Phone #_____________________________
Leader’s Address __________________________Town______________________ Zip_______________
Leader’s Email Address _________________________________________________________________
PART II: AMOUNT REQUESTED : (List specific $ dollar amounts)
Annual Membership Registration
$ 15.00 (Approved pending completion of this application)
Activity/ Event
Amount
No. of Girls Attending
______________________________ $__________
_______
______________________________ $__________
_______
______________________________ $__________
_______
______________________________ $__________
_______
______________________________ $__________
_______
______________________________ $__________
_______
Training
Amount
______________________________ $__________
______________________________ $__________
PART III: FAMILY INFORMATION:
Please explain circumstances/reasons for requesting financial assistance. Use additional
paper if necessary.
___________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________
Completed by: __________________________________ Date:_________________________
Relationship to applicant: Troop Leader___ Other ___
Office Use:
Amount of Grant $_________________ Date Approved: _________
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