Membership Financial Aid Application

Girl Scouts Spirit of Nebraska is committed to providing all girls and adults the opportunity to participate in the Girl Scout Leadership Experience.

Please complete one form per household. You may apply for up to four girls and two parents/caregivers per application. This application will automatically omit sections that do not apply to you.

NOTE: Adults may only apply for financial aid if they are a Troop Co-Leader, reside in either Rock County or Sherman County, Nebraska, or have a WellCare/Healthy Blue Medicaid Health Plan.

If you have any questions, please email us or call 402.558.8189.

Section 1: Household Information

Who Are You Applying For? (check all that apply) *

Girl(s)

Parent/Caregiver(s)

Adult Full Name: *

Adult Date of Birth: * +

Street Address: *

Apt. #:

City: *

State: *

ZIP Code: *

Phone: *

Email: *

Section 2: Girl Information

Not Applicable

How Many Girls Are You Applying For? (up to 4) *

Girl Applicant 1

Girl Full Name: *

Date of Birth: * +

School: *

Grade: *

Five Digit Troop Number: 🛈

Race: *

Ethnicity: *

1. Did she participate in the most recent Girl Scout Cookie or Fall Product Program? (select "N/A" if she was not an active member during either sale). *

2. Requesting Aid For (check all that apply): *

Annual Membership Registration Fee

Membership Materials

2a. Membership Materials: *

Girl Applicant 2

Girl Full Name: *

Date of Birth: * +

School: *

Grade: *

Five Digit Troop Number: 🛈

Race: *

Ethnicity: *

1. Did she participate in the most recent Girl Scout Cookie or Fall Product Program? (select "N/A" if she was not an active member during either sale). *

2. Requesting Aid For (check all that apply): *

Annual Membership Registration Fee

Membership Materials

2a. Membership Materials: *

Girl Applicant 3

Girl Full Name: *

Date of Birth: * +

School: *

Grade: *

Five Digit Troop Number: 🛈

Race: *

Ethnicity: *

1. Did she participate in the most recent Girl Scout Cookie or Fall Product Program? (select "N/A" if she was not an active member during either sale). *

2. Requesting Aid For (check all that apply): *

Annual Membership Registration Fee

Membership Materials

2a. Membership Materials: *

Girl Applicant 4

Girl Full Name: *

Date of Birth: * +

School: *

Grade: *

Five Digit Troop Number: 🛈

Race: *

Ethnicity: *

1. Did she participate in the most recent Girl Scout Cookie or Fall Product Program? (select "N/A" if she was not an active member during either sale). *

2. Requesting Aid For (check all that apply): *

Annual Membership Registration Fee

Membership Materials

2a. Membership Materials: *

Section 3: Parent/Caregiver Information

NOTE: Adults may only qualify for financial aid if they are a Troop Co-Leader, reside in Rock County, NE, or have a WellCare/Healthy Blue Medicaid Health Plan.

Not Applicable

How Many Adults Are You Applying For? (up to 2) *

Parent/Caregiver Applicant 1

Is this parent/caregiver also a Troop Co-Leader? *

Parent/Caregiver Full Name: *

Date of Birth: * +

Phone: *

Email: *

Race: *

Ethnicity: *

Parent/Caregiver Applicant 2

Is this parent/caregiver also a Troop Co-Leader? *

Parent/Caregiver Full Name: *

Date of Birth: * +

Phone Number: *

Email Address: *

Race: *

Ethnicity: *

Section 4: Qualifying Financial Information

NOTE: Adults may only qualify for financial aid if they are a Troop Co-Leader, reside in Rock County, NE, or have a WellCare/Healthy Blue Medicaid Health Plan.

1. Do you live in either Rock County or Sherman County, Nebraska? *

2. Do you have a WellCare/Healthy Blue Medicaid health plan? *

WellCare/Healthy Blue ID Number(s): *

0/100 characters

3. Are you associated with any social service organizations? *

Which Organization? *

4. Did a caseworker refer you? *

Caseworker's Name: *

5. Explain why you are requesting financial aid: *

0/500 characters

Section 5: Signature

I certify that all of the information on this application is true and complete.

Applicant Initials: *

Date: *

Signature: *

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