Destination Scholarship Request Form
Destinations Scholarships is one of the many services provided by Girl Scouts of Wisconsin Southeast. Girl Scouts may receive a Destination scholarship of up to $1,000, based on available funding. Scholarship award amounts are determined by factors including available funds, the number of applicants, and demonstrated financial need. Priority is given to Girl Scouts experiencing a first-time Destination.
CONTACT INFO
Girl Scout Name
*
First Name
Last Name
Girl Scout Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Girl Scout Email
*
example@example.com
Girl Scout Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
PRODUCT SALE INFO
Has Girl Scout participated in most recent/current Girl Scout Cookie Program?
*
Yes
No
If 'yes' to previous questions, how many boxes were sold?
Will Girl Scout be participating in the upcoming Girl Scout Cookie Program season?
*
Yes
No
Has Girl Scout participated in most recent/current Fall Product Sale?
*
Yes
No
Will Girl Scout be participating in the upcoming Girl Scout Fall Product Sale?
*
Yes
No
HOUSEHOLD INCOME INFO
Select your current household income:
*
$0-$25,000
$25,001-$50,000
$50,001-$75,000
$75,001-$100,000
$100,001-$125,000
$125,001+
Number of People Living on Household Income
*
DESTINATION INFO
Destination Title
*
Destination Location
*
Destination Host (e.g. name of Girl Scout council or business organizing Destination)
*
Destination Start Date
*
-
Month
-
Day
Year
Date
Destination End Date
*
-
Month
-
Day
Year
Date
DESTINATION FEES
Event Fee
*
Estimated Additional Travel Fees (Travel ticket fees to and from the destination’s starting point can be included for economy seating; however, additional charges such as baggage fees and other travel add-ons are not covered.)
*
Attached copy of estimated travel ticket fees from ticketing website?
*
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Total Fees (Event Fee + Estimated Additional Travel Fees)
*
Amount Family Can Pay
*
Scholarship Amount Requested (Girl Scouts may receive a Destination scholarship of up to $1,000, based on available funding. Scholarship award amounts are determined by factors including available funds, the number of applicants, and financial need. Scholarship requests cannot exceed the combined total of the event fee and estimated travel fee)
*
GIRL SCOUT STATEMENT OF NEED
This section must be completed by the Girl Scout.
Why do you think you should be considered as a recipient for a scholarship?
*
How will you contribute financially to this trip?
*
PARENT/GUARDIAN STATEMENT OF NEED
This section must be completed by the parent/guardian.
Please state specific reasons why a scholarship is needed
*
REQUIREMENTS FOR RECIPIENTS OF A DESTINATION SCHOLARSHIP
As the parent/guardian of the Girl Scout requesting scholarship funds, I under stand: 1) Our Girl Scout must be a registered member of GSWISE, 2) All application information is kept confidential, 3) Girl Scout must commit to actively participate in the upcoming Cookie Program Activity and work to exceed or sell at the council goal level, 4) Scholarship priority will be given to Girl Scouts experiencing a first-time Destination, 5) We will receive an e-mail indicating the amount granted and must sign an award agreement before any funds are released, and 6) Scholarship award will be released to the sponsoring organization and any difference above the balance due will be released to the participant.•
*
I agree
As the parent/guardian of the Girl Scout requesting a scholarship, I agree to give service back to the Girl Scout community by (check all that apply):
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Attending a troop meeting with my Girl Scout
Attending a council event with my Girl Scout
Assisting with day camp
Assisting the service center with business mailings or other light administrative projects
Assisting in some other way with GSWISE or in our Girl Scout community
Other
All participants that receive a scholarship will be required to complete/submit the following after their trip: 1) GSUSA's Destination Evaluation Form, 2) Pictures of trip, and 3) GSWISE Photo Release Forms, 4) Participate in an interview with the GSWISE Marketing and Communications team, 5) Provide copy of travel receipts (if scholarship requested includes travel fees), and 6) Any remaining scholarship funds (if applicable).
*
I agree
Attach a copy of your acceptance letter/email from the Destination host.
*
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