Financial Assistance Application Form Financial Assistance Request ...
Financial Assistance Application Form Financial Assistance Request ...
Financial Assistance Application Form Financial Assistance Request ...
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<strong>Financial</strong> <strong>Assistance</strong> <strong>Application</strong> <strong>Form</strong><br />
<strong>Financial</strong> <strong>Assistance</strong> <strong>Request</strong> for:<br />
Uniform Insignia & Publications | Troop Dues | Events (Please circle)<br />
Adult /Girl /Troop Leader (Please circle one)<br />
Membership Year: 2010-2011<br />
Important: Sections A and B must be completed in order to process the request.<br />
Incomplete forms will result in a processing delay.<br />
Allow four (4) to six (6) weeks for processing.<br />
Girls Scouts in the Heart of PA has a financial assistance fund to assist girls who might otherwise be<br />
unable to participate in Girl Scouting. <strong>Financial</strong> assistance is designed to supplement family resources,<br />
not replace them. Every attempt is made to grant the items requested however, there may be items<br />
denied due to funding constraints and/or eligibility issues. <strong>Financial</strong> assistance is granted only for the<br />
items listed on this form. All applications are confidential and only shared as necessary with appropriate<br />
staff members to determine eligibility for assistance.<br />
Mail completed form to: Girl Scouts in the Heart of Pennsylvania | ATTENTION: <strong>Financial</strong> <strong>Assistance</strong><br />
Administrator | 350 Hale Avenue | Harrisburg, PA 17104<br />
SECTION A – Girl or Adult Information-One <strong>Form</strong> per Applicant<br />
Name<br />
Address<br />
City State Zip Code<br />
( )<br />
Daytime Phone<br />
Email Address<br />
Service Unit Number County Position/Grade Level<br />
Troop Number Troop Leader Phone Number<br />
Leader’s Address City State Zip Code<br />
SECTION B – Family Information<br />
Applicant or Parent/Guardian Name<br />
Employed by<br />
Parent/Guardian Name<br />
Employed by<br />
( )<br />
Phone<br />
Title/Position<br />
( )<br />
Phone<br />
Title/Position<br />
Number of dependent children at home:<br />
Do your children receive subsidized school meals? Yes No<br />
Is your child(ren) home schooled? Yes No<br />
Gross Family Income (from your most recent tax return): $<br />
Total number of persons dependent on Household Income _ _____<br />
Check all that apply toward household income:<br />
Unemployment<br />
SSI<br />
Disability<br />
Salaries<br />
Child Support<br />
Other<br />
08/2010 – krose Girl Scouts in the Heart of Pennsylvania | 350 Hale Avenue | Harrisburg, PA 17104 | 800.692.7816 | general@gshpa.org
<strong>Financial</strong> <strong>Assistance</strong> <strong>Application</strong> <strong>Form</strong><br />
<strong>Financial</strong> <strong>Assistance</strong> <strong>Request</strong> for:<br />
Uniform Insignia & Publications | Troop Dues | Events (Please circle)<br />
Adult /Girl /Troop Leader (Please circle one)<br />
Membership Year: 2010-2011<br />
Why are you requesting <strong>Financial</strong> <strong>Assistance</strong>? (Please add a separate piece of paper if additional space is<br />
needed)<br />
I hereby attest that the information I have provided on this form is, to the best of my knowledge, correct. I<br />
will be held financially responsible for any fees not covered by approved financial assistance.<br />
Signature of Applicant or Parent/Guardian<br />
Date<br />
Please check if item(s) requested can be discussed with Troop Leader. Yes No<br />
SECTION C – <strong>Request</strong> for <strong>Financial</strong> <strong>Assistance</strong> for Training-Council-Troop-Service Unit Programs/Events<br />
Name of Activity<br />
Date(s) of Activity<br />
Location of Activity<br />
Please specify SU, Troop, or GSHPA Activity<br />
TOTAL COST OF ACTIVITY $<br />
Amount troop funds will pay: -<br />
Amount of Service Unit support: -<br />
Amount applicant can pay: -<br />
Amount provided by other sources (gift, fundraising, troop): -<br />
Sub Total: $<br />
TOTAL AMOUNT REQUESTED<br />
$<br />
Please attach a copy of the flyer/letter for the Activity requested. *Exception GSHPA Programs*<br />
A check for the total amount award will be mailed directly to troop leader. Applicant portion should be paid directly to troop leader.<br />
SECTION D – <strong>Request</strong> for <strong>Financial</strong> <strong>Assistance</strong> for Troop Dues<br />
Troop dues per meeting: $<br />
Number of meetings:<br />
x<br />
Total cost of dues $<br />
Amount family can pay: -<br />
Sub Total: $<br />
TOTAL AMOUNT REQUESTED $<br />
A check for the total amount award will be mailed directly to troop leader. Applicant portion should be paid directly to troop leader.<br />
08/2010 – krose Girl Scouts in the Heart of Pennsylvania | 350 Hale Avenue | Harrisburg, PA 17104 | 800.692.7816 | general@gshpa.org
<strong>Financial</strong> <strong>Assistance</strong> <strong>Application</strong> <strong>Form</strong><br />
<strong>Financial</strong> <strong>Assistance</strong> <strong>Request</strong> for:<br />
Uniform Insignia & Publications | Troop Dues | Events (Please circle)<br />
Adult /Girl /Troop Leader (Please circle one)<br />
Membership Year: 2010-2011<br />
SECTION E – <strong>Request</strong> for <strong>Financial</strong> <strong>Assistance</strong> for Girl Uniforms/Journey Books<br />
CHECK<br />
CHECK<br />
ITEM<br />
PRICE<br />
ITEMS<br />
ITEMS<br />
ITEM<br />
PRICE<br />
Daisy<br />
Junior<br />
Daisy Tunic S/M (6-7) $13.00 Junior Sash 52” long $5.50<br />
Daisy Tunic L/XL (8-10) $13.50 Junior Sash 62” long $6.00<br />
Daisy Girl Scout Pin $1.50 Junior Vest Specify Size: $15.75<br />
Daisy Activity Book $8.25 Junior Vest Plus Size $16.75<br />
Daisy Numerals List: $1.25 ea Girl Scout Pin Traditional/Contemporary $2.00<br />
Daisy GSUSA/GSHPA ID Strip Set $4.00 Junior Numeral(s) List: $1.25 ea<br />
Brownie Junior GSUSA/GSHPA ID Strip Set $4.00<br />
Brownie Sash 47” long $5.25 Cadette/Senior/Ambassador<br />
Brownie Sash 59” long $5.75 Cadette/Senior Sash 70 ½ “ long $6.50<br />
Brownie Vest Specify Size: $15.75 Cadette/Senior Sash 75 ½ “ long $7.00<br />
Brownie Vest Plus Specify Size: $16.75 Cadette/Senior Vest Specify Size: $20.50<br />
Brownie Pin Traditional/Contemporary $1.50 Cadette/Senior Plus Specify Size: $23.50<br />
Brownie Numeral(s) List: $1.25 ea Girl Scout Pin Traditional/Contemporary $2.00<br />
Brownie GSUSA/GSHPA ID Strip Set $4.00 Girl Scout Numeral(s) List: $1.25 ea<br />
World Trefoil Pin $2.25 Girl Scouts GSUSA/GSHPA ID Strip Set $4.00<br />
Journey 1 Books<br />
Journey 2 Books<br />
Welcome to the Daisy Flower Garden $7.00 Daisy – Between Earth and Sky $7.00<br />
Brownie Quest Book $7.00 Brownie – WOW! Wonders of Water $7.00<br />
Junior Agent of Change Book $7.00 Junior – GET MOVING! $7.00<br />
Cadette aMAZE! Book $7.00 Cadette – BREATHE $7.00<br />
Senior – GIRLtopia $7.00 Senior – SOW WHAT? $7.00<br />
Ambassador – Your Voice, Your<br />
World<br />
$7.00 Ambassador – Justice $7.00<br />
Other<br />
Wavy American Flag Patch $1.75<br />
Insignia Tab Specify Level: $2.50<br />
Membership Star $1.00<br />
TOTAL AMOUNT OF REQUEST FOR UNIFORMS/JOURNEY BOOKS $<br />
SECTION F – <strong>Request</strong> for <strong>Financial</strong> <strong>Assistance</strong> for Try-Its/Badges/Patches/Pins<br />
Date Earned Item Name Description (Try-IT, Badge, Patch) OFFICE USE ONLY<br />
08/2010 – krose Girl Scouts in the Heart of Pennsylvania | 350 Hale Avenue | Harrisburg, PA 17104 | 800.692.7816 | general@gshpa.org
<strong>Financial</strong> <strong>Assistance</strong> <strong>Application</strong> <strong>Form</strong><br />
<strong>Financial</strong> <strong>Assistance</strong> <strong>Request</strong> for:<br />
Uniform Insignia & Publications | Troop Dues | Events (Please circle)<br />
Adult /Girl /Troop Leader (Please circle one)<br />
Membership Year: 2010-2011<br />
PUBLICATIONS<br />
QTY Title Price Total QTY Title Price Total<br />
Focus Books<br />
Handbooks/Badge Books<br />
Don’t Sweat It $4.95 Brownie Girl Scout Handbook $11.95<br />
Express It $4.95 Brownie Handbook and Try-Its Book Set $20.00<br />
Focus College 101 $5.95 Spanish Language Brownie Handbook/Try-Its $14.95<br />
Got Money $4.95 Try-Its for Brownie Girl Scouts $9.95<br />
Go for It – Silver $5.25 Junior Girl Scout Handbook $10.95<br />
Go for It – Gold $5.25 Junior Girl Scout Handbook and Badge Book $21.50<br />
Insert – On the Money $5.25 Junior Girl Scout Badge Book $11.95<br />
Looking in, Reaching Out $5.95 Cadette Girl Scout Handbook $11.50<br />
Making Waves $4.95 Interest Projects for Girls $9.95<br />
Mind Your Own Business $4.95 Resource Book for Senior Girl Scouts $10.95<br />
On the Go $4.95 Leader Guides-Leaders Only<br />
On the Road $5.95 The Guide for Daisy Girl Scout Leaders $9.00<br />
On Track $4.95 The Guide for Brownie Girl Scout Leaders $5.95<br />
Parks Matter $4.95 The Guide for Junior Girl Scout Leaders $6.00<br />
Take Charge $4.95 Journey 2 How to Guide-Leaders Only<br />
The Real Deal $5.95 Daisies/Between Earth & Sky Girl’s Book Set $15.00<br />
Write Now $4.95 Brownies/WOW! Wonders of Water Book Set $15.00<br />
Journey 1 How to Guide-Leaders Only Juniors/GET MOVING! Girl’s Book Set $15.00<br />
Daisy – Flower Garden $15.00 Cadettes/BREATHE Girl’s Book Set $15.00<br />
Brownie – Quest $15.00 Seniors/SOW WHAT? Girl’s Book Set $15.00<br />
Junior – Agent of Change $15.00 Ambassadors/JUSTICE Girl’s Book Set $15.00<br />
Cadette – aMAZE! $15.00<br />
Senior – Girltopia $15.00<br />
Ambassador – Your Voice $15.00 TOTAL AMOUNT OF PUBLICATIONS REQUESTED: $<br />
Troop Leaders Only – if requesting publication for troop use solely.<br />
Balance-Most recent <strong>Financial</strong> Report: $<br />
Please attach a copy of your most recent <strong>Financial</strong> Report<br />
Why is your Troop <strong>Request</strong>ing <strong>Financial</strong> <strong>Assistance</strong> for Publications:<br />
SECTION G – <strong>Request</strong> for <strong>Financial</strong> <strong>Assistance</strong> for Adult Uniform Insignias ( Check items needed.)<br />
Girl Scout Pin<br />
Adult Position Pin<br />
World Trefoil Pin Green Insignia Tab<br />
Contemporary/Traditional<br />
(Leader – Yellow)<br />
Adult: Please explain how the requested items will be used to further Girl Scout programs in your area:<br />
08/2010 – krose Girl Scouts in the Heart of Pennsylvania | 350 Hale Avenue | Harrisburg, PA 17104 | 800.692.7816 | general@gshpa.org
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