Local Council Service Fee Financial Assistance Application

Date / MM / DD YYYY
Parent/Guardian Information
Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone * - ### - ### ####
Email *
Amount of assistance applying for? (Up to $72 Council Service Fee for 2023 - please note, this amount will be prorated depending on the month you join) * $ . Dollars Cents
Does your child receive Free or Reduced Lunches from their school? *

Does your child receive Free or Reduced Lunches from their school? YES NO
Does your Unit participate in the Council Fundraiser (popcorn)? *

Does your Unit participate in the Council Fundraiser (popcorn)? YES NO
Do you or a family member volunteer with your child's Unit? *

Do you or a family member volunteer with your child's Unit? YES NO
Members in Scouting
Full Name of Scout First Last
Relationship
District
Unit Type
Unit #
Full Name of Scout First Last
Relationship
District
Unit Type
Unit #
Full Name of Scout First Last
Relationship
District
Unit Type
Unit #
If more than 3 Scouts, add additional names, relationship, and units in this box.
What was your annual family income? * $ . Dollars Cents
Reason why you are asking for Financial Assistance: *
Are there any extenuating circumstances that we need to be aware of? *
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. *
YES
Draw your signature into the box below. *

Clear
Date Signed * / MM / DD YYYY