Girl Member Registration Form - 2016-2017

2016-2017 Girl Member Registration Form

Farthest North Girl Scout Council  Council Code: 600  Girl Membership $20 per Girl Scout Year

PLEASE PRINT CLEARLY

MEMBERSHIP

Troop #:

or Individual/Juliette

Service Unit:

ID#

EXPIRATION

New Member (first time registering)

Re-registering: This is my ____________ year in Girl Scouts.

9 - 30 - 2017

PROGRAM LEVEL (check one):

Girl Scout Daisy (

Girl Scout Brownie (

Girl Scout Junior (

K-1)

Grade 2-3)

Grade 4-5)

Girl Scout Cadette (

Girl Scout Senior (

Girl Scout Ambassador (

Grade 6-8)

Grade 9-10)

Grade 11-12)

First Name:

Middle Name:

Last Name:

Mailing Address:

Apt. #:

PO Box:

City:

State:

Zip:

Phone: (

)

Cell:* (

)

Check if this is a new address within the last year.

Previous Address:

Birthdate:

/

/

Grade Fall 2015:

School:

MM

DD

YYYY

Girl's E-mail (If different from parent/guardian):

Ms.

Mrs.

Miss

Mr.

Parent/Guardian Name:

Home Phone: (

)

Address (if different from girl's):

Employer:

Position:

Work Phone: (

)

E-mail:*

Cell Phone:* (

)

Ms.

Mrs.

Miss

Mr.

Parent/Guardian Name:

Home Phone: (

)

Address (if different from girl's):

Employer:

Position:

Work Phone: (

)

E-mail:

Cell Phone:* (

)

By completing the following optional questions, you can help ensure community support and funding for Girl Scouts. Girl Scouts respects and welcomes people from all

backgrounds and abilities. This information is used for statistical purposes only. Thank you for providing the information requested.

Race/Ethnicity/Language

A. Mark one

B. Are you Hispanic/Latino?

Alaskan Native

Hawaiian or Pacific Islander

(Complete A, B & C)

or more:

American Indian

Caucasian

yes

no

Asian

Other

(Complete A and B)

yes

C.

African American

First language, if not English:_______________

$35,000 to

$70,000 to

Annual Household Income: (Optional)

Learning

My daughter qualifies for free or reduced-priced lunch.

<$35,000

$70,000

$105,000+

I would like to contribute:

I understand that my voluntary tax deductible gift will help to support girls locally and will remain in the local council

(check one)

$25.00

$50.00

$100.00

Credit Card #__________________________ Exp. date_______

$150.00

$200.00

Other: $________

Signature:_________________________________________

The council may NOT use photographs, audio recordings, quotes, stories or videotape of my daughter/girl to help promote Girl Scouting.

I am requesting assistance with the $20 annual membership dues. I can pay $_________ toward the $20 dues.

We acknowledge that the registrant will make the Girl Scout Promise and accept the Girl Scout Law. The registrant has our permission to join Girl Scouts. We understand that

when participating in Girl Scout activities the registrant may be photographed for print, video, or electronic imagine. We understand that the images may be used in promotional

materials, news releases, and other published formats for either the local Girl Scout Council or Girl Scouts of the U.S.A. We acknowledge that the images will be the sole

property of either the local Girl Scout Council or Girl Scouts of the U.S.A.

Signature: _______________________________________________________________________

Date:_____________________________________________________

Data Privacy Policy: Girl Scouts is committed to respecting the privacy of our members. We do not sell or trade membership lists, contact information, or any other personal data about

individual members for any reason.

Cash_________

CK#_________  

Charge _______

Financial Aid_____

Troop

Camp

Indiv.

Event

Other

Office Use Only: Date Received:

Initials:

Receipt #:

E-Council Entry: