Volunteer Assistance Application

VOLUNTEER ASSISTANCE APPLICATION

Full Legal Name

Address

City

State

Zip

Day Phone

Evening Phone

District

Neighborhood

Have you attended this type of event previously?

Did you receive funding assistance from GSEM?

I am currently a registered Girl Scout adult volunteer.

Please complete the following about the opportunity:

Girl Scout adult position(s)

EDUCATION

Course Name

Sponsoring Organization

District

Neighborhood

Location of Course

Date(s)

FEES

Tuition

Books (if applicable)

Other (describe)

Total

Personal Contribution

Amount Requested

Date Needed

Reason assistance is requested

Check range of total family gross income per year (please include child support, social security, public assistance, etc.)

I understand that funds will not be awarded if Girl Scout membership cannot be verified. Requests may be awarded for full or partial amounts. Please allow up to 4 weeks for processing.

Signature

GSEM is a proud United Way member and is supported by the following United Way Agencies: United Way of Greater St. Louis, United Way of the Mark Twain Area, United Way of Adair County/Northeast Missouri, United Way of St. Francois County, Franklin County Area United Way