Girl Scout 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.
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.
Members may substitute wording appropriate to their
own spiritual beliefs for the word “God.”
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.
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
Girl Membership: $
Adult Membership(s): $
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
Name: First Middle Last
Address Apartment City State/Zip
( )
Primary Phone required �Mobile �Home Parent’s Email Address required
Date of birth (mm/dd/yyyy) School grade in Fall 2021 Name of school
Custodial care:
� Both Parents
� Mother/Guardian Only
� Father/Guardian Only
� Other
She is: (check all that apply)
�
American Indian or
Alaskan Native
� Asian
� Black or African American
� Hawaiian or Pacic
Islander
� White
�
Other (please specify)
� I choose not to share at
this time
She is Hispanic or Latina:
� Yes
� No
�
I choose not to share
at this time
Girl Scouts respects and welcomes people from all backgrounds and abilities. By completing the above 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 is reported separately. This information is
used for statistical purposes only.
Parent/Guardian (1) First Name Middle Last
Address � Same as girl
( ) ( )
Primary Phone required �Mobile �Home Secondary Phone �Mobile �Home I wish to opt in: �*Texts
Email Address required Date of birth (mm/dd/yyyy) required Gender
� I also wish to become a member this year for $25 (required to volunteer, see membership options to the right).
Parent/Guardian (2) First Name Middle Last
Address � Same as girl
( ) ( )
Primary Phone Secondary Phone I wish to opt in: �*Texts
Email Address Date of birth (mm/dd/yyyy) Gender
� I also wish to become a member this year for $25 (required to volunteer, see membership options to the right).
District Neighborhood Troop Check one: � New Member � Renewing Member
PARENT/GUARDIAN INFORMATION DEMOGRAPHICS GIRL INFORMATION
Signature of Parent/Guardian Date
I/We acknowledge the registrant will accept and abide by the Girl Scout Promise and Law. The registrant has permission to join Girl Scouts.
Membership fees are nonrefundable and nontransferable. Please allow six weeks for processing.
PERMISSION
Registration and nancial assistance are available online at girlscoutsem.org/join
F-51
Return membership form and payment to:
Girl Scouts of Ea stern Missouri
PO Box 795226
St. Louis, MO 63179-0795
Any adult working directly with girls must be registered, background checked and approved as a Girl Scout volunteer.
Any adult working directly with girls must be registered, background checked and approved as a Girl Scout volunteer.
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 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.
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
*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.
Square Confirmation #
