Girl/Adult Financial Assistance Form

GSNNJ Girl/Adult Financial Assistance

GSNNJ is committed to assuring that all girls and adults who want to participate in the Girl Scout program have the opportunity. The Council’s financial assistance program attempts to remove financial barriers that may prevent participation. Complete all information. Grants are available to registered members to supplement the cost of participation in approved programs based on financial need. All application information will be kept confidential.
*Please note: Financial Assistance for MEMBERSHIP is a different form, and MUST BE REQUESTED by contacting Customer Care at customercare@gsnnj.org, or by calling (973) 248-8200.
Check One:*

New MemberRenewing Member
Girl Name*

First NameLast Name
Service Unit #
Troop #
Girl's Birthdate*
(mm/dd/yyyy)
Grade as of Fall 2024*
School Name*
Girl's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Custodial Care:*

Both ParentsParent & Secondary ContactParentGuardianGuardian & Secondary Contact
If not both parents, then who is the custodial parent
She is (check all that apply):*

WhiteAmerican Indian/Alaskan NativeAsianBlack/African AmericanHawaiian or Pacific IslanderOther
Girl is Hispanic or Latina:*

YesNo
Caregiver Name*

First NameLast Name
Caregiver address if different from Girl's:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver's Birthdate*
(mm/dd/yyyy)
I am the Primary Caregiver/Contact (as listed above)*

YesNo
Caregiver Gender:*

FemaleMale
Caregiver Race (check all that apply):*

WhiteAmerican Indian/Alaskan NativeAsianBlack/African AmericanHawaiian or Pacific IslanderOther
Caregiver is Hispanic or Latina:*

YesNo
By opting in for emails and text alerts, you agree to receive important information concerning membership, programs, cancellations, and closures as applicable. Understanding such content is not required to join. I wish to opt in for:*

TextsEmailsNeither
Caregiver's E-mail*
example@example.com
Caregiver's Mobile/Cell Number*
In order to accommodate girls of all abilities, please indicate if your child has any disabilities as defined by the Americans with Disabilities Act:*

YesNo
If yes, what accommodations does your child need:
Single Parent Household:*

NoYes-FemaleYes-Male
TOTAL Household Income FY2024:*

$0 - $34,999$35,000 - $49,999$50,000 - $74,999$75,000 - $99,999$70,650 - $99,999$100,000 - $149,999$150,000 - $199,999$200,000 - $249,999$250,000+
Total number of family members this income supports*
Age of siblings
Age of siblings (please place commas between ages)
Occupation of Father
Is the Girl Scout's father currently employed?

YesNo
Occupation of Mother
Is the Girl Scout's mother currently employed?

YesNo
Extenuating Circumstances
Leader's Name

First NameLast Name
Leader's Phone Number
Please enter a valid phone number.
Leader's Email
example@example.com
Girl Scout Level:*

Daisy, Grades K-1Brownie, Grades 2-3Junior, Grades 4-5Cadette, Grades 6, 7, & 8Senior, Grades 9-10Ambassador, Grades 11-12
Indicate below the type of assistance requested, and provide additional information as needed.
UNIFORM COMPONENTS

Please check the item(s) you wish to request.

If requesting a sash or vest, please choose either
a sash OR a vest; not both.
Sash (please indicate size, using the chart below)Vest (please indicate size, using the chart below)Tunic - for Daisies only (please indicate size, using the chart below)American Flag PatchCouncil ID PatchMembership Pin / Daisy Pin (for Daisies only)World Association PinGirl Scout HandbookJourney book
Size of vest, sash, or tunic?
If asking for Financial Aid for uniform components, from which Service Center would you like to pick up the uniform components?

Jockey Hollow Camp Trading Post, 10 Ledell Road in Mendham (Mondays)Riverdale Service Center, 95 Newark Pompton Turnpike (Tuesdays-Fridays)Paramus Service Center, 300 Forrest Avenue (Mondays-Fridays)
PROGRAMS

All Financial Assistance forms for girls' Programs MUST be received two weeks BEFORE the opening date for registration.
PROGRAM NAME
Program Link #
Dollar Amount You Are Requesting:
Program Registration Opening Date

MonthDayYear
Date
Please list all program dates and times you are available to attend. Please DO NOT list any dates you are unable to attend.
1st Choice Date and Time blanks Location blank
2nd Choice Date and Time blanks Location blank
3rd Choice Date and Time blanks Location blank
CAMPERSHIPS

Please register/enroll your child(ren) in summer camp online before submitting this application:

https://www.gsnnj.org/en/members/for-girl-scouts/camp-and-outdoors/girl-scouts-love-state-parks.html
CAMPERSHIP

Register/enroll in summer camp online before submitting this application. The 2025 CAMPERSHIP SUBMISSION DEADLINE IS APRIL 1, 2025. All 2025 Campership recipients will be notified by April 30, 2025. Proof of total household income is required.
DESTINATIONS

The deadline to apply for financial aid for Destinations is March 15.
DESTINATIONS

Submit with acceptance letter - Deadline March 15Program Activity FormGSNNJ Agreement Form
Total Fees:*
Dollar amount the family will contribute toward the cost of these total fees:*
Dollar amount the family is requesting from GSNNJ:*
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. (When making the Girl Scout Promise, individual members may substitue 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.
I accept and abide by the Girl Scout Promise and Law:*

YesNo
When participating in Girl Scout activities, I (or the person I am registering) give consent to be interviewed, photographed, videotaped, or electronically imaged for purposes of promotional materials, news releases, or other published formats for either the local Girl Scout Council or Girl Scouts of the USA. The images will be the sole property of the local Girl Scout Council or Girl Scouts of the USA. I hereby release and hold harmless the local Girl Scout Council and Girl Scouts of the USA from any claim arising from the use of these images. I accept the Media Permission:*

YesNo
I understand that this programming is made possible through grant funding. As a requirement of this grant, my demographic data may be released to the grantor for data reporting purposes. I consent to this release of data and understand that it is being utilized for informational purposes only. By my signature below, I affirm that I have read this release and I comprehend its content.
Caregiver/Contact Signature and CC Authorization. This signature serves as permission for the registrant to join Girl Scouts.*

Clear
Signature Date*

MonthDayYear
Date
Should be Empty:

GSNNJ Girl/Adult Financial Assistance

*Please note: Financial Assistance for MEMBERSHIP is a different form, and MUST BE REQUESTED by contacting Customer Care at customercare@gsnnj.org, or by calling (973) 248-8200.