Adult Education Course Registration Form
Adult Education course registration forms are accepted via US mail or email at firstname.lastname@example.org.
Registration forms must be received and processed one week prior to the course registration close date. Submit
one form per person, per course. Mail completed registration forms to:
a. Forms with no payment attached: Girl Scouts of Eastern Missouri 2300 Ball Drive St. Louis, MO 63146
b. Forms with attached payment: Girl Scouts of Eastern Missouri PO Box 795226 St. Louis, MO 63179-0795
Confirmation emails with course details will be sent approximately one week before the course date. If you do not
receive a confirmation email within the timelines specified, contact the Answer Center.
Cancellations and Refunds
To receive a refund, individuals wishing to cancel must provide written notification prior to the program’s
registration deadline. Registration cancellations must be emailed to the Answer Center at
answerce nte r@girlsco utsem.org. No refunds will be given after the registration close date.
Scholarships are available for courses supported and maintained by Girl Scouts of Eastern Missouri. To apply for a
scholarship, the Adult Education Scholarship Application must be submitted with the Course Registration form.
Adult Education Course Name ______________________________________________________________________
Course Date _________________, Location ________________________________, and cost ___________________
Full Name of Applicant ____________________________________________________________________________
Street Address ___________________________________City ___________________State ______ Zip __________
Day Phone (____) ____________ Evening Phone (____) ____________ Email ________________________________
I am a currently registered Girl Scout adult volunteer in District _____ Neighborhood _____ Troop ______________
Girl Scout volunteer role(s)_________________________________________________________________________
Method of Payment if Applicable
All monies received are cashed or charged when received by Girl Scouts of Eastern Missouri.
Check all that apply: ___ Check or Money Order ___ Debit Card ___ Visa ___ MasterCard ___ Discover
Program Fee Amount $_______________
Charitable Gift Enclosed $_______________
Total Fee (A+B) $ _______________
Credit Card Information Account Number ______________________________ Exp. Date _________ CSV ________
Cardholder's Signature ____________________________________________________Date ____________________
Dietary Restrictions and Accommodations
Please note any special dietary restrictions: ___________________________________________________________
Girl Scouts of Eastern Missouri welcomes the participation of all girls and adults and will make reasonable
accommodations needed by persons with disabilities. If you have questions or want to discuss an
accommodation, please contact the Answer Center at 314.400.4600 or email@example.com
Do you need a reasonable accommodation? ____ Yes ____ No
If so, what is needed? _____________________________________________________________________________
Signature ___________________________________________________________________ Date _______________
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