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/guardians per application. This application will automatically omit sections that do not apply to you.

If you have any questions, please email us or call 800.695.6690.

Section 1: Household Information

Who Are You Applying For?
NOTE: Adults may only apply for financial aid if they are a troop co-leader, reside in Rock County, NE, or have a WellCare/Healthy Blue Medicaid Health Plan. *

Girl(s)

Parent/Guardian

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? *

Girl Applicant 1

Girl Full Name: *

Date of Birth: * +

School: *

Grade: *

5-Digit Troop #: 🛈

Race: *

Ethnicity: *

1. Did she participate in the most recent Girl Scout Cookie or Fall Product Program? *

Yes

No

N/A, was not an active member during either sale

2. Requesting Aid For: *

Annual Membership Registration

Membership Materials (Uniform or Book)

2a. Membership Materials: *

Uniform

Book

Girl Applicant 2

Girl Full Name: *

Date of Birth: * +

School: *

Grade: *

5-Digit Troop #: 🛈

Race: *

Ethnicity: *

1. Did she participate in the most recent Girl Scout Cookie or Fall Product Program? *

Yes

No

N/A, was not an active member during either sale

2. Requesting Aid For: *

Annual Membership Registration

Membership Materials (Uniform or Book)

2a. Membership Materials: *

Uniform

Book

Girl Applicant 3

Girl Full Name: *

Date of Birth: * +

School: *

Grade: *

5-Digit Troop #: 🛈

Race: *

Ethnicity: *

1. Did she participate in the most recent Girl Scout Cookie or Fall Product Program? *

Yes

No

N/A, was not an active member during either sale

2. Requesting Aid For: *

Annual Membership Registration

Membership Materials (Uniform or Book)

2a. Membership Materials: *

Uniform

Book

Girl Applicant 4

Girl Full Name: *

Date of Birth: * +

School: *

Grade: *

5-Digit Troop #: 🛈

Race: *

Ethnicity: *

1. Did she participate in the most recent Girl Scout Cookie or Fall Product Program? *

Yes

No

N/A, was not an active member during either sale

2. Requesting Aid For: *

Annual Membership Registration

Membership Materials (Uniform or Book)

2a. Membership Materials: *

Uniform

Book

Section 3: Parent/Guardian Information

(Not Applicable)

How Many Adults Are You Applying For?
NOTE: Adults may only apply for financial aid if they are a troop co-leader, reside in Rock County, NE, or have a WellCare/Healthy Blue Medicaid Health Plan. *

Caregiver Applicant 1

Is this parent/guardian also a troop co-leader? *

Yes

No

Caregiver Full Name: *

Date of Birth: * +

Phone: *

Email: *

Race: *

Ethnicity: *

Caregiver Applicant 2

Is this parent/guardian also a troop co-leader? *

Yes

No

Parent/Guardian Full Name: *

Date of Birth: * +

Phone Number: *

Email Address: *

Race: *

Ethnicity: *

Section 4: Qualifying Financial Information

Adults not registered as troop co-leaders will receive financial aid for membership ONLY if they have a WellCare/Healthy Blue Medicaid Health Plan or live in Rock County, Nebraska.

1. Do you live in Rock County, NE? *

Yes

No

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

Yes

No

WellCare/Healthy Blue ID #: *

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3. Are you associated with any of the listed organizations? *

4. Did a caseworker refer you? *

Yes

No

Caseworker's Name: *

5. Explain why you are requesting financial aid: *

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Section 5: Signature

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

Applicant Initials: *

Signature: *

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