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Other (please specify)
� I choose not to share at this
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I choose not to share
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The Girl Scout Promise
On my honor, I will try:
To serve God* and my country,
To help people at all times,
And to live by the Girl Scout Law.
The Girl Scout Law
I will do my best to be
honest and fair,
friendly and helpful,
considerate and caring,
courageous and strong, and
responsible for what I say and do,
and to
respect myself and others,
respect authority,
use resources wisely,
make the world a better place, and
be a sister to every Girl Scout.
Adult Membership
MEMBERSHIP OPTIONS
Annual Membership
� $25 (annual fee)
Membership from Oct. 1, 2021-Sept. 30, 2022
Extended Year Membership
� $35 (new or lapsed members)
Membership from April 1, 2021-Sept. 30, 2022
Young Alumnae Lifetime Membership
� $200 (one-time fee)
Former girl member, who is 18-29 years old
Lifetime Membership
� $200 (one-time fee)
Adult, 18 years or older, who has
completed 10 or more years of continuous
adult membership to Girl Scouts
� $400 (one-time fee)
Adult, 18 years or older, who is not a former
girl member or a former girl member who is
30 years or older.
Each year, our scholarship program
covers membership dues for
thousands of girls in eastern Missouri.
Help make Girl Scouting possible for
every girl. Donate today!
I would like to donate:
� $10 � $25 � $50 � $100 � $250
� Other: $
Receive a patch and segment with a
donation of $25 or more.
Donations are 100% tax-deductible.
PAYMENT and PROCESSING
Annual Membership: $
Lifetime Membership: $
Gifts for Girls Donation: $
Total Attached: $
Payment Options
� Check or Money Order, payable to GSEM
� Financial Assistance Request attached
(annual and extended year membership only)
Join the global network of 2.7 million Girl Scouts
DEMOGRAPHICS
PARTICIPATION
CONTACT INFORMATION
Girl Scouts respects and welcomes
people from all backgrounds and
abilities. By completing the following
information as defined by the US
Census, you ensure support and
funding for girls in your community.
Hispanic/Latina is dened as an
ethnicity, not a race, therefore
reported separately. This information
is used for statistical purposes only.
I accept and will abide by the Girl Scout Promise and Law:
Signature Date
ACCEPTANCE
F-52
Registration and nancial assistance are available online at girlscoutsem.org/join
As a member, I would like to participate in the following ways:
� 01- Leader for Troop #
� 02- Assistant Leader for Troop #
� 03- Support Volunteer Troop #
� Cookie Manager for Troop #
� Fall Product Manager for Troop #
� Alumna
� Staff Member
� Other
Any adult working directly with girls must be registered, background checked and approved as a Girl Scout volunteer.
Return membership form and payment to:
Girl Scouts of Ea stern Missouri
PO Box 795226
St. Louis, MO 63179-0795
Membership fees are nonrefundable
and nontransferable. Please allow
six weeks for processing.
District Neighborhood Troop Check one: � New Member � Renewing Member
Media Permission
For good and valuable consideration, the receipt
and sufficiency of which are hereby acknowledged, I
hereby consent and agree to the following:
1. I acknowledge that I am eighteen (18) years of age
or older. I hereby grant to Girl Scouts of Eastern
Missouri (“GSEM”), and its successors and assigns
(each a “Releasee”), the irrevocable, royalty-free,
perpetual, unlimited right and permission to use,
distribute, publish, exhibit, digitize, broadcast,
display, modify, create derivative works of,
reproduce or otherwise exploit my name, picture,
likeness and voice (including any video footage of
the same), testimonials (written by me or attributed
to me), interviews (written by me or attributed
to me) (collectively, “Media”), or to refrain from
so doing, anywhere in the world, by any persons
or entities deemed appropriate by GSEM, for any
purpose including, without limitation, any use
for educational, advertising, non-commercial or
commercial purposes in any manner or media
whatsoever (whether known or hereafter devised)
including, without limitation, on the internet, in print
campaigns, in-store and via television. I agree that I
have no interest or ownership in any of the Media.
2. I shall have no right of approval, no claim to
compensation and no claim (including, without
limitation, claims based upon invasion of privacy,
defamation or right of publicity) arising out of any
use, alteration, blurring, illusionary effect or use in
any composite form of my name, picture, likeness
and voice. I agree that nothing in this Release will
create any obligation on GSEM to make any use of
the Media or the rights granted in this Release. I
hereby release and hold harmless Releasees from
any claim for injury, compensation or negligence
resulting or arising from any activities authorized by
this Release and any use of the Media by GSEM.
� I wish to opt out at this time.
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*By signing below and checking the above circles, each signee agrees to receive auto-dialed information,
marketing text messages or emails, and other transactional service-relationed messages to the email
address and phone number above, understanding such consent is not required to join.
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