FA ALT REG FORM

Girl Financial Assistance Registration

Girl Scout memberships are valid 10/1 through 9/30. Use this form to request Girl financial assistance for the annual membership fee for the 2019 - 2020 membership year. If you are not in need of financial assistance, but would like to pay with cash, check, or Cookie Dough, please complete this form and send payment along with the name of person to be registered and the email address of adult completing request to Attn: Finance Dept., GSGATL, 5601 North Allen Road, Mableton, GA 30126
Membership Status *

New Member Returning Member
Membership Year *

2020 Membership (valid 10/1/2019 through 9/30/2020) 2021 Membership (valid 10/1/2020 through 9/30/2021)
Troop Number (if known) or School Name *
Alternate Payment Options *
Girl's Name *

First Name Last Name
Girl's Date of Birth *

Month Day Year
Girl's Race (Choose all that apply) *

Am. Indian or Alaskan Native Asian Black or African American Hawaiian or Pacific Islander White Other Races I Choose Not to Share
Girl's Ethnicity *

Hispanic Non-Hispanic I Choose Not to Share
Full Name of School Attending *
Current Grade *
Caregiver's Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
County *
Caregiver's E-mail *
Caregiver's Primary Phone Number *

Area Code Phone Number
Caregiver's Date of Birth

Month Day Year
Caregiver's Race (Choose all that apply) *

Am. Indian or Alaskan Native Asian Black or African American Hawaiian or Pacific Islander White Other Races I Choose Not to Share
Caregiver's Ethnicity *

Hispanic Non-Hispanic I Choose Not to Share
Volunteer Position
"Troop" roles require a criminal background check.
Financial Assistance
If you are seeking general financial assistance to be paid by Girl Scouts of Greater Atlanta, please provide the following:
I am able to pay a portion of the annual membership fee, to be mailed to Council, in the amount of
I am unable to pay any portion of the annual membership fee due to:
Caregiver's Insurance Type

Wellcare Care Source
For Amerigroup and Care Source members, please provide the Member Number. For WellCare members, please provide your WellCare Member ID.
Please attach a clear photo/scan of your membership card
Wellcare and Care Source adults also qualify for a free Girl Scout adult membership. Would you like to add an adult membership to be paid through your insurance?

Yes No, Thank You
Please enter the Wellcare or Care Source Member Number for the Adult Caregiver
Please contact Peach State Member Services in order to obtain your Girl Scout voucher to complete the membership process. Peach State Customer Care can be reached at 800-704-1484, Monday – Friday from 7 a.m. – 7 p.m.

Only Valid between April 1 - October 31, 2020
Peach State subscribers are not eligible for their membership benefits between November 1, 2019
and March 31, 2020 (Girl Scout membership and $15 Badge & Sash voucher). Please select Peach State to complete your daughter's Girl Scout membership.
Communications
Opt Out of Text Messaging

I wish to opt out of receiving text messages from Girl Scouts of Greater Atlanta at this time
Opt Out of Email Messaging.

I wish to opt out of receiving email messages from Girl Scouts of Greater Atlanta at this time.
Membership Registration Acceptance for Household
I accept and will abide by the Girl Scout Promise and Law *

Yes, I will.
When participating in Girl Scout activities I may be photographed for print, videotaped, or electronically. Images may be used in promotional materials, news releases,and other published formats for either Girl Scouts of Greater Atlanta or Girl Scouts of the USA. The images will be the sole property of Girl Scouts of Greater Atlanta or Girl Scouts of the USA.

I wish to opt out at this time.
Should be Empty:

Girl Financial Assistance Registration

Communications

Membership Registration Acceptance for Household