GSHPA Financial Assistance Application
Families are able to use the online registration pages to submit their information and troop preferences, and at the end check a box to indicate they are interested in paying for their girl's membership fee with Financial Assistance. If you have not yet completed the online registration, please click HERE or contact us at 717-233-1656.
Parent/Guardian Name
*
First Name
Last Name
I am applying for financial assistance to cover the following;
*
Search
Girl Scout Membership and Troop Funds
Service Unit Day Camp/Camporee/Encampment
Outdoor Experience
Please Select
If applying for financial assistance to cover Girl Scout Membership and Troop Funds, please select if this is for a new or renewed membership.
New Girl Scout Membership
Girl Scout Membership Renewal
How many girl members are applying for Financial Assistance?
*
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0
1
2
3
4
Please Select
How many adult members are applying for Financial Assistance?
*
Search
0
1
2
3
Please Select
I have already completed the registration process and either paid the membership fee or checked the box requesting Financial Assistance:
*
Yes
No
No, please contact me with more information
Girl 1 Name
*
First Name
Last Name
Girl 1 Troop Number
*
Girl 2 Name
*
First Name
Last Name
Girl 2 Troop Number
*
Girl 3 Name
*
First Name
Last Name
Girl 3 Troop Number
*
Girl 4 Name
*
First Name
Last Name
Girl 4 Troop Number
*
Are any of the girls listed above a part of the foster care system? If so, please note their name here (these children automatically qualify per our current guidelines, regardless of income and household size).
Adult 1 Name
*
First Name
Last Name
Adult 1 Role
*
Search
Adult Member
Troop Leader
Troop Activites Chaperone
Service Unit Support Volunteer
Service Unit Lead
Please Select
Adult 2 Name
*
First Name
Last Name
Adult 2 Role
*
Search
Adult Member
Troop Leader
Troop Activites Chaperone
Service Unit Support Volunteer
Service Unit Lead
Please Select
Adult 3 Name
*
First Name
Last Name
Adult 3 Role
*
Search
Adult Member
Troop Leader
Troop Activites Chaperone
Service Unit Support Volunteer
Service Unit Lead
Please Select
E-mail Address
*
example@example.com
Daytime Phone Number
*
-
Country Code
-
Area Code
Phone Number
County in which your family resides
*
Search
Adams
Carbon
Centre
Clinton
Columbia
Cumberland
Dauphin
Franklin
Fulton
Huntingdon
Juniata
Lackawanna
Lancaster
Lebanon
Luzerne
Lycoming
Mifflin
Monroe
Montour
Northumberland
Perry
Pike
Schuylkil
Snyder
Sullivan
Susquehanna
Union
Wayne
Wyoming
York
Please Select
Notes/Comments
E-mail Address
*
example@example.com
Daytime Phone Number
*
-
Country Code
-
Area Code
Phone Number
Girl Scouts Name
*
First Name
Last Name
Service Unit # (3-digits)
Camp/Event Name:
*
Camp Location (City/Campground):
*
Camp Directors Name:
*
Service Unit Camp Start Date:
*
/
Month
/
Day
Year
Date
Cost of Camp/Event
*
E-mail Address
*
example@example.com
Daytime Phone Number
*
-
Country Code
-
Area Code
Phone Number
Girl Scouts Name
*
First Name
Last Name
This Outdoor Experience can be categorized as a
*
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Individual Experience
Troop Experience
Please Select
Troop Number (5-digits):
*
Who is sponsoring the Outdoor Experience your Girl Scout wishes to attend?
*
Girl Scouts in the Heart of Pennsylvania
Other Girl Scout Council
Non-Girl Scout Organization
Name of the organization sponsoring the Outdoor Experience
*
Outdoor Experience Name:
*
Location of Outdoor Experience:
*
Outdoor Experience Start Date:
*
/
Month
/
Day
Year
Date
Cost of Troop Outdoor Experience
*
Please explain what ascpect of the event/trip qualify it as an Outdoor Experience?
Gross Household Income per Year (Income includes employment, assistance, SSI, Child Support, etc.)
*
Total number of individuals living in the household:
*
Signature of Applicant or Parent/Guardian:
*
*
By checking this box, I agree this will serve as my electronic signature.
Please verify that you are human
*
Submit
Should be Empty: