GIRL MISSION Adult Membership Girl builds girls of courage, Join the global network of 3.2 million Girl Scouts confidence, and character, who Membership Year through 9/30/2015 make the world a better place.

MEMBERSHIP OPTIONS: Check one: � New Member � Renewing Member � Lifetime Member GSUSA ID (if known) Annual Membership Title or salutation: � Mrs. � Ms. � Miss � Mr. � Dr. � Other: � Annual fee: $15

Lifetime Membership Name: First Middle Last (including permanent membership card and recognition certificate)

Address Apartment � One-time fee of $375: Adults 18 years of age or older City State Zip Code � One-time fee of $195: ( ) ( ) Girl Scout Ambassadors Home Phone Business Phone graduating from High School ( ) in this membership year in the Cell Phone E-mail Address month of: (please submit by Sept. 1st of CONTACT INFORMATION CONTACT Employer Title/Occupation graduating year)

I wish to opt in: � Texts � E-mails By signing here and checking the circles to the left, each signee (and on behalf of the Girl, as applicable) agrees to receive autodialed informational or marketing text messages at the cell YES! I would also like to make a number above, understanding such consent is not required to join. donation today that directly benefits girls in our area. Enclosed Girl Scouts respects and welcomes Gender: # of years in Girl Scouting: Date of birth: is my tax-deductible donation people from all backgrounds and � Female as a girl: / / in the amount of: (check one) abilities. By completing the following � Male as an adult: mm dd yyyy � $500 � $250 � $150 information (as defined by the US � $100 � $50 � $25 Census), you ensure support and I am: (check all that apply) I am Hispanic or Latina: � Other: $ funding for girls in your community. � American Indian � White � Yes Hispanic/Latina is defined as an or Alaskan Native � Other (please specify) � No ethnicity, not a race, therefore � Asian � I choose not to share PAYMENT INFORMATION: DEMOGRAPHICS reported separately. This information � Black or African American � I choose not to share at this time is used for statistical purposes only. � Hawaiian or Pacific Islander at this time Annual Membership: $ Lifetime Membership: $ I will be participating in Girl Scouting as: (check all that apply) � Volunteer­—I am/will be volunteering for Girl Scouts � Community Partner Donation: $ � Parent/Family­—I am a parent/guardian/family member of a Girl Scout � Staff—I am/will be employed by Girl Scouts Total Attached: $ � Girl Scout Alumnae­—I was a Girl Scout, either as a girl, adult or both � Other � Cash � Check* As a volunteer, I would like to participate in the following role(s): Representing Group(s)/Troop(s)/Service Unit Numbers: � Amex � Discover � 01—Advisor or Leader for a Group/Troop # # # # � 02—Assistant Advisor or Leader for a Group/Troop Advisor/Leader # # # � Visa � MasterCard � 03—Support Volunteer for a Group/Troop # # # � Other PARTICIPATION � 11—Service Team or Unit Volunteer SU SU SU � 12—Learning Facilitator Name on Credit Card � Other (specify)

Media Permission The Girl The Girl Credit Card # When participating in Girl Scout activities (I or the On my honor, I will try: I will do my best to be

person I am registering) give consent to be inter- To serve God and my country, honest and fair, Expiration Date viewed, photographed, videotaped, or electronically To help people at all times, friendly and helpful, imaged for the purposes of promotional materials, And to live by the Girl Scout Law. considerate and caring, news releases, or other published formats for either courageous and strong, and Signature the local Girl Scout Councils or Girl Scouts of the When making the GS Promise, responsible for what I say and do,

USA. The images will be the sole property of the local individual members may substitute and to Date Girl Scout Council or Girl Scouts of the USA. I hereby wording appropriate to their own spiritual respect myself and others, release and hold harmless the local Girl Scout Council beliefs for the word “God.” respect authority, *Make checks payable to Girl Scouts and Girl Scouts of the USA from any claim arising from use resources wisely,

ACCEPTANCE the use of these images. make the world a better place, and THANK YOU FOR be a sister to every Girl Scout. � I wish to opt out at this time. SUPPORTING GIRL SCOUTS! Learn more about Girl Scouts at I accept and abide by the Girl Scout Promise and Law: www.girlscouts.org.

Return this registration form, along Signature Date with GSUSA annual membership fee or applicable Lifetime fee to your local council. Fees are non-refundable or Council Code: Service Unit/Team: Group/Troop:

USE transferable to another person. ADMIN