Membership Scholarship Application

Thank you for your interest in becoming a Girl Scout! We offer a variety of financial support options to support your Girl Scout journey. Your health insurance provider may cover wellness benefits that include Girl Scout participation, and our learn-as-you-earn programming through product sales can help cover many out-of-pocket expenses. Additionally, the Council invests in a membership scholarship fund to ensure all girls have the opportunity to participate. To be considered for these opportunities, please fill out the information below. You will be notified of your registration status soon.

Are you requesting financial support for a Girl membership or an Adult membership?

Girl Full Name

First NameLast Name

Adult Full Name

First NameLast Name

Date of Birth

Date

Are you a Girl Scout Volunteer?

What is your volunteer role?

Are you insured by any of the following health insurance?

Aetna Better Health Kentucky reimburses parents for their daughter's membership dues in the form of a gift card.

Members can receive a $50 gift card to pay for Girl Scouts of the United States of America and other established community organizations, afterschool programs or organized team sport programs.

Eligibility Criteria: Members ages 6-18 who have completed a well child visit within the last 12 months Limits & Restrictions: Limit to one per child per year. Must have record of well child visit. SKY Members are excluded.

To request reimbursement, parent's must provide the receipt from purchasing their daughter's membership to Aetna Better Health Kentucky Customer Service: 1-855-300-5528

If YES, please provide the Member ID

Please upload a copy of your insurance card:

School Attending

Girl Scout Level

Number of Years as a Girl Scout

Parent/Guardian Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Has/will your girl be participating in the Fall Product or Cookie Program?

Financial Information Request

To ensure we can continue offering meaningful scholarship opportunities to Girl Scouts in our council, we respectfully request that you provide basic financial information as part of this application.

Collecting this information allows us to demonstrate the need for financial assistance to our current supporters—including grant funders and donors—and strengthens our ability to secure future funding for the Girl Scout Scholarship Fund. Your information will be kept confidential and used solely for reporting and development purposes.

Number of Adults Living in Home

Number of Children Living in Home

Household Income

What scholarship amount are you requesting?

Remember to ALSO select your requested sholarship amount at check-out!

By signing my name below, I am verifying that the above information is accurate to the best of my knowledge.

Today's Date

Date

Girl Scout Membership

Girl Scout membership fee. The final amount may be reduced based on the scholarship amount selected on the form.

$65.00 Requested Scholarship Amount

Total

Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info