Financial Assistance Form

GSNNJ Financial Assistance Form - Destinations

GSNNJ is committed to helping more girls and adults participate in the Girl Scout Leadership Experience program and activities. 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. We at GSNNJ value the diversity of the community we serve. This information is strictly for internal use only.
DESTINATIONS

The deadline to apply for financial aid for Destinations is March 15.
Check One:*

New MemberRenewing/Existing Member
Girl Scout Name*

First NameLast Name
Service Unit #
Troop #
Girl Scout Birthdate*
(mm/dd/yyyy)
Grade as of Fall 2024*
School Name*
Girl Scout 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
Girl Scout is (check all that apply):*

WhiteAmerican Indian/Alaskan NativeAsianBlack/African AmericanHawaiian or Pacific IslanderPrefer not to answerOther
Girl Scout is Hispanic or Latina:*

YesNo
Primary Caregiver's Name*

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

Street Address

Street Address Line 2

CityState / Province

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

YesNo
Primary Caregiver's Gender:*

FemaleMaleOther (Non-binary)
Primary Caregiver's Race (check all that apply):*

WhiteAmerican Indian/Alaskan NativeAsianBlack/African AmericanHawaiian or Pacific IslanderPrefer not to answerOther
Primary 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
Primary Caregiver's Email*
example@example.com
Primary Caregiver's Mobile/Cell Number*
Secondary Caregiver's Email
example@example.com
Secondary 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-MaleYes-Other (Non-binary)
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 (please place commas between ages)
Occupation of Primary Caregiver
Is the Girl Scout's Primary Caregiver currently employed?

YesNo
Occupation of Secondary Caregiver
Is the Girl Scout's Secondary Caregiver currently employed?

YesNo
Extenuating Circumstances
Girl Scout Level:*

Cadette, Grades 6, 7, & 8Senior, Grades 9-10Ambassador, Grades 11-12
DESTINATION NAME:
DESTINATION'S HOST COUNCIL NAME:
Do you have the acceptance letter from the Destination's Host Council?

YesNo
Do you have the Destination's detailed itinerary of program activities?

YesNo
Total Fees for your Destination:*
Dollar amount the family is able to contribute toward the cost of these total fees:*
Dollar amount the family is requesting from GSNNJ*:*
*Please note that the dollar amount requested cannot be the same amount as the total fees.
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.
Primary Caregiver/Contact Signature*

Clear
Signature Date*

MonthDayYear
Date
Should be Empty:

GSNNJ Financial Assistance Form - Destinations