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:

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 402.558.8189

Section 1: Applicant Information

Parent/Caregiver Full Name: *

Girl Full Name: *

Street Address: *

Apt. #:

City: *

State: *

ZIP Code: *

Phone: *

Email: *

Girl Date of Birth: * +

Girl Grade: *

FIve Digit Troop Number: 🛈

Section 2: Qualifying Financial Information

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: *

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

Which Organization? *

4. Did a caseworker refer you? *

Caseworker's Name: *

5. Did your Girl Scout participate in the most recent Girl Scout Cookie or Fall Product Program? (select "N/A" if your girl 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: *

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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: *

Program 1 Name: *

Program 1 Date: * +

Program 1 Location (City): *

Program 1 Fee: *

Program 2 Name: *

Program 2 Date: * +

Program 2 Location (City): *

Program 2 Fee: *

Section 4: Signature

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

Applicant Initials: *

Date: *

Applicant Signature: *

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