Rev JT 3/2018
Financial Assistance Request for Membership Dues
1. This form must be attached to a completed membership form in order to be processed
2. Complete a separate form for each person requesting assistance
3. Mail this form with the membership form to:
Girl Scouts of Eastern Missouri, 2300 Ball Drive, St. Louis, MO 63146
Applicant Information
Full Name of applicant:
Applicant is a: Girl (under age 18) Adult
Troop Number:
Check the range of your total household income over the last year (include all sources of
income, such as child support, unemployment, disability, social security, public assistance, etc.):
$0 - $14,999 $35,000 - $49,999 $75,000 - $99,999
$15,000 - $34,999 $50,000 - $74,999 $100,000 or more
Please indicate which product programs the applicant has participated in within the last year:
Fall Product program Cookie program Neither, please explain:
Is there a special circumstance you would like for us to consider when processing this request?
Payment Information
Please select your Membership Option:
Annual Membership fee: $25
(membership valid from October 1 through September 30)
Extended Year Membership fee: $35
(for new or lapsed members, this membership is valid from April 1 through the next September 30)
Girl Scouts of Eastern Missouri has limited scholarship assistance funds available. Please
consider if your family or troop can pay a portion of the membership cost. Any amount you can
contribute allows us to serve more girls.
Amount Enclosed: ____________
Parent or Guardian Signature: Date:
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