Girl Scouts Of Northeast Texas Adult Registration Form
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1Girl Scouts of Northeast Texas
ADULT REGISTRATION -
Council Code 597
Membership Year 20
- 20
Return with $15 annual membership dues to the troop leader.
Troop #
SU #
............................
....................
Check one:
New
Reregistering
Lifetime Member
Please check your Volunteer Role:
Troop Leader
Your name and address:
Assistant Leader
Co-Leader
Troop Cookie Manager
Name:
First
Middle
Last
Troop Volunteer
Mailing Address / Apartment #
What is the Girl Scouts of
Northeast Texas
City
State
Zip Code
County
Family Partnership
Campaign?
Home Phone
Cell Phone Number
The GSNETX Family Partnership
Employer
Business Phone
Campaign is a way for Girl Scout
families to invest in girls’ futures
E-mail
by providing the financial support
needed to support all of the things
...............................................................................................................# of completed yrs in Girl Scouting as a:
Girl
.........
Adult
.........
your daughter loves about Girl Scouts.
Birthdate
Annual fees go directly to GSUSA,
By entering your email address above, you give GSNETX permission to send council news to the address listed.
however money raised through Family
GSNETX will not share, sell distribute or rent your information to anyone.
Partnership stays here at Girl Scouts
of Northeast Texas! That means 100
percent of Family Partnership money
We encourage you to provide the following information on racial background and ethnicity as well as gender.
This information will be used to improve our outreach efforts and advance the Girl Scout Movement.
goes towards the camps she loves, to
the volunteers who support her, and
1. My racial background is: (check one)
American Indian or Alaskan Native
Asian
Black or African American
the programs she’ll talk about all year!
Hawaiian or Pacific Islander
White
Other
Your donations help make it all possible,
2. My ethnic background is: (check one)
Hispanic or Latina/Latino
Not Hispanic or Latina/Latino
participate in Family Partnership today!
3. I am an adult:
Female
Male
What Your Gift Can Do!
$50 - Sends a Girl Scout Troop Leader
to a CPR or First Aid Certification Class.
I accept and agree to abide by the Girl Scout Promise and the Girl Scout Law. I understand that when participating in Girl Scout activities the reg-
istrant may be photographed for print, video or electronic imaging. I understand the images may be used in promotional material, news releases,
$75 - Helps girls experience water
and other formats for either Girl Scouts of Northeast Texas or Girl Scouts of the USA. I acknowledge that the images will be the sole property
safety by providing 3 life vests.
of either Girl Scouts of Northeast Texas or Girl Scouts of the USA. I agree to abide by the Volunteer Terms and Conditions for adult members
$100 - Feeds 9 horses in Camp Bette
located at:
Perot’s Equestrian Program for one
week.
Signature .....................................................................................................
Date ....................................
$250 - Sends a girl to camp for one
Lifetime Member
week.
$500 - Provides membership to 40 girls
I am currently a Lifetime Member, please update my current information. NO DUES REQUIRED
in an elementary Girl Scout troop in an
underserved community.
I wish to register as a Lifetime Member. I am 18 years of age or older or a high school graduate or equivalent and understand that
$1,000 - Provides a Girl Scout Gold
lifetime membership is a one-time payment of $375.
Award recipient a scholarship to the
college of her choice and you will be
I am currently registered as a Senior Girl Scout and graduated from high school/equivalent in this membership year in the month of
............................
I understand that I can register for lifetime membership at the reduced cost of $195 if I do so before my current
recognized in the Second Century
membership expires on September 30.
Circle.
(Membership dues are not refundable or transferable to another person)
Membership
15
GSUSA Membership Dues $___________
Cash
$__________
Check #
__________
Financial Assistance Request
ed
(payable to Girl Scouts of Northeast Texas)
Credit Card #
__________________________________________________________________
CVV#:
______________
Billing Zip:
_________________
Name on Credit Card_____________________________________________Exp
Date_____________
VISA
MasterCard
Signature______________________________________________________Date________________
.....................................................................................................
...........................
Discover
Am. Express
Family Partnership - Give the Gift of Girl Scouting!
I want to support the Girl Scout Leadership Experience with a gift of:
$1,000
$500
$100
$50
$35
Other
$_________
Charge Credit Card # above
TOTAL TO CHARGE CREDIT CARD: (Membership and Family Partnership)
$_______________
Girl Scouts of Northeast Texas
6001 Summerside, Dallas, TX 75252
972-349-2400
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