Temp Girl Grant Application for Membership

Girl Grant Application for Membership, Uniforms and Insignia
Please complete this form to apply for a GSNENY Girl Grant for Membership and/or Girl Scouts uniforms and insignia.

Applications are accepted at any time and are awarded based on financial need as long as funds are available.

Any/all Cookie Dough, Program Vouchers, or store gift cards that a girl has earned will be applied prior to Girl Grant funds being used.

Please fill in all required fields as incomplete applications will be delayed. If you have questions or need assistance, call Customercare@girlscoutsneny.org or call 518.-489-8110.
Girl Scout Information
Name of Girl Scout*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Girl Scout's Grade (In Summer time list grade entering in Fall)*
County where Girl Scout Resides*
School Girl Scouts Attends*
Troop Number
Service Unit Number
Girl Scout Level*

Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Caregivers DOB*

MonthDayYear
Date
Address Same as Girl Scout
Address - if different than Girl Scout

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Addition Parent/Guardian Name (if applicable)

First NameLast Name
Address Same as Girl Scout
Address - if different than Girl Scout

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com

Please describe the circumstances or financial situation that led you to request a Girl Grant.*

Membership or Uniform Information
Please indicate the membership for which you are requesting assistance:*

New Girl Scout MembershipGirl Scout Membership Renewal
Please indicate the uniform items for which you are requesting assistance:*

Uniform Tunic or SashAge Level PinCouncil ID SetTroop Numerals
Girl Scout Level*
If applying for a uniform, at which Service Center will you pick it up?
I understand that Girl Grants funds are intended to remove cost as a barrier to participation in Girl Scouts. By submitting this Girl Grant Application, I attest that the information I have provided my financial need is truthful to the best of my knowledge.
Digital Signature*
Should be Empty: