Request for IRM Funds

Individually Registered Girls (IRGs) should plan their Girl Scout year and submit this form for approval. Requests are accepted year round.

By submitting this form, you are stating that you have participated in a Girl Scout Council of the Southern Appalachians product sale program and are currently registered. All monies due and all required paperwork were turned in as directed.

Name*

Girl's First NameGirl's Last Name

Service Unit # Or Service Unit Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Did the applicant participate in the Fall Product Program?*

YesNo

What Year(s)?*

Did the applicant participate in the Cookie Sale?*

YesNo

What Year(s)?*

Requesting Reimbursement? (receipts should be attached below)*

YesNo

Check Request*

YesNo

Checks Made to:*

IRG funds are for GIRL USE ONLY. Funds should be requested in advance. All items are subject to review by theGSCSA Program Specialist and funds will be paid directly to GSCSA or other Vendor. You may request reimbursement for items already purchased for service or high award projects only. For reimbursement, you must attach receipts to this form. No payments will be made directly to the IRG or parent without receipt(s) for expenses. Funds may not be requested for parents or for items unrelated to Girl Scouting. Direct all questions to the Outreach Programs Manager.

I am requesting funds for (check all that apply):*

Membership Registration (annual membership and council service fee totals $35)Council Store PurchaseCouncil EventService Unit EventHigh Award projectService or Take Action ProjectCouncil or GSUSA-sponsored travelLifetime Membership (suggested for graduating high school seniors - $200)

Council Store Purchase (IRG funds may be used for uniform components, badges, GSLE printed materials like Journeys, Girl's Guide to Girl Scouting, and fun patches. You may call the shop to place your order and obtain a total. Please attach your shop order form to this form at the bottom.)

Council Event*

List the events and the amount due per event

Service Unit Event*

List the events and the amount due per event

High Award Project*

List the type of project (Bronze, Silver, or Gold Award), describe need, and the amount needed.

Service or Take Action Project*

Describe service project or Take Action project, describe need, and the amount needed.

Council or GSUSA-Sponsored Travel (IRG funds can only be used for travel that is hosted by GSCSA or sponsored by GSUSA, meaning Destinations or other GSUSA experiences. Include as much information about the trip as you can here, including the amount requested, and attach any supporting documentation like acceptance letters, deposit receipts, etc.)*

Upload any receipts or supporting documentation:

Browse Files

Requested By (name of IRG):*

(Signature of Juliette)

Signature of IRG's parent/guardian :*

Date*

Date

By submitting this form, you are attesting that the included inforamtion is accurate and funds are only being used for the regsitered Girl Scout girl member.
Send any questions to: info@girlscoutcsa.org
Please allow up to 10 business days for processing.

Request for Funds from IRG Account