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Adult Education Scholarship Application for Adults
Financial assistance is available to volunteers who wish to take Adult Education courses that have a fee and are
supported and maintained by Girl Scouts of Eastern Missouri Adult Education Department. For example: First Aid,
CPR/AED, Wilderness and Remote First Aid, Cooking for Crowds at Camp, Troop Camp Certification Courses, Small
Craft Safety Training, and USA Level 1 Archery are eligible for a scholarship.
The Answer Center must receive this completed application via email before the course registration period ends.
Submit one application per adult per course. Eligibility rules apply to all applications. See details on page 2.
PLEASE PRINT
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)_________________________________________________________________________
Number of individuals in your household: _______ Age of each dependent child in your household: _____________
Check the range of your total household gross income over the last year (include all sources of income such as
child support, unemployment, disability, social security, public assistance, etc.:
$0-$19,999 $40,000-$49,999 $70,000- 79,999 $100,000-$109,999
$20,000-$29,999 $50,000-$59,999 $80,000-$89,999 $110,000-$119,999
$30,000-$39,999 $60,000-$69,999 $90,000-$99,999 Over $120,000
Last Girl Scouts of Eastern Missouri scholarship award received: Date: ______________ Amount: ______________
Are there any special circumstances we should consider with this financial assistance request?
________________________________________________________________________________________________
________________________________________________________________________________________________
Please complete the following about the learning opportunity that a scholarship is being requested:
Adult Education Course Name ______________________________________________________________________
Course Date ________________, Location ______________________________, and cost ______________________
All scholarships require that a portion of the program cost be paid by the member and/or troop. Please provide
the amount you can contribute at this time. You will be notified of your remaining balance due once the
scholarship award decision is finalized.
Personal Contribution: $____________________
Scholarship Amount Requested $____________________
Signature: ___________________________________________________________________ Date: ______________
_______________________________________________________________________________________________
For Office Use Only
Calc: ____________ Amt Approved: ________________ Due: ________________ Date Due: ________________ Emailed: ____
Task: ___ Processing Staff Initials: _________________ Approving Staff Initials: _________________ Date: ________________
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