Girl Scouts Heart of Michigan
Financial Assistance Request for Girl Scout Uniforms, Insignia and/or Program Books

Girl Scouts Heart of Michigan provides financial assistance for registered girl members. This assistance is to help in meeting the cost of Girl Scout vest or sashes, insignia and or grade-level program books. Financial assistance is granted on need and the availability of funds.

To apply, use the form below. Please submit a separate application for each girl. Fill out the form neatly and completely, listing all information requested. Return the completed form in a sealed envelope to your Troop Leader or to the nearest Girl Scouts Heart of Michigan regional center marked-Attn: Membership Team Leader. You may have to pay a portion of the cost and are encouraged to contribute back to the financial assistance fund whenever possible. All information is confidential.

| Date | Area | Troop Number |
| |
|Troop Level: ο Daisy ο Brownie ο Junior ο Cadette ο Senior ο Ambassador |
| Girl’s Name |
| |
| Street Address |
| |
| City, State, Zip | Phone |
| | |
| Parent/Guardian’s Name |
| |
| Parent/Guardian’s E-mail |

Has a parent/guardian in the household been unemployed over the past year: ( Yes ( No If so, how many months?

Comments/factors to be considered that impact the financial need. (Explanations might include school tuition, medical expenses, unemployment, divorce, death in the family, family emergency or other contributing factors):

# of Adults in household? # of children (under 18) in household?

Current family/household income (salaries/unemployment) $ ________________ per year.

Income from additional sources $ per year. Source: ____________________________________________________

Amount family can pay $

Amount Requested:$

Parent/Guardian’s Signature: Date:

Return the completed form in a sealed envelope to your Troop Leader or to the nearest Girl Scouts Heart of Michigan regional center marked-Attn: Membership Team Leader.
____________________________________________________________

______________________________________________________

-----------------------
OFFICE USE ONLY

Membership ID # Girl’s Name ____________________________________________________________

_____

FS IR EC Total / $

Date Received Date Approved Amount Granted $

Account # __________10 3 8900 1510 (location code) Revised 7/16/2010 - ko