Girl Program 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 (GSLE).

NOTES:

Financial Aid may be requested for up to 50% of council-sponsored program fees for girls only, not for adult or sibling fees.
Please complete one form per girl. You may apply for up to two programs per application.
Girls must be registered Girl Scout members to attend council-sponsored programs. Please click here to request financial aid for membership.

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

Section 1: Applicant Information

Caregiver Full Name: *

Girl Full Name: *

Street Address: *

Apt. #:

City: *

State: *

ZIP Code: *

Phone: *

Email: *

Girl Date of Birth: * +

Girl Grade: *

5-Digit Troop #: 🛈

Section 2: Qualifying Financial Information

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

Yes

No

2. Do you have a WellCare/Healthy Blue Medicaid Health Plan? *

Yes

No

Wellcare/Healthy Blue ID #: *

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

4. Did a caseworker refer you? *

Yes

No

Caseworker's Name: *

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

Yes

No

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

6. Please explain why financial aid is being requested, including any special circumstances that you or your family are experiencing: *

0/500 characters

Annual Household Income (Pre-Tax): *

Number In Household: *

	Total
Adults:	Total
Dependents:	Total
Girl Scouts:	Total

Section 3: Program Fee Request

Requesting Aid For This Number of Programs: *

1

2

Program 1 Name: *

Program 1 Date: * +

Program 1 Location: *

Program 1 Fee: *

Program 2 Name: *

Program 2 Date: * +

Program 2 Location: *

Program 2 Fee: *

Section 4: Signature

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

Applicant Initials: *

Applicant Signature: *

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