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Information

Membership Assistance

Application for membership assistance.

Membership Assistance Application

District(Required)

Algonquian

Dunes Moraine

Pioneer Trails

Potawatomi

Unit Type(Required)

Pack

Troop

Crew

Post

Ship

Is this for a new or existing Scout?(Required)

New

Existing

Unit Number(Required)

Scout's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Primary Parent/Guardian Name(Required)

First Last

Email(Required)

Phone(Required)

Employer(Required)

Occupation(Required)

Other Parent/Guardian Name

First Last

Phone

Employer

Occupation

Amount of Membership Assistance Requested(Required)

Please enter a number from 0 to 95.

Gross Monthly Income in $0.00(Required)

Other Monthly Income in $0.00 (Alimony, Child Support, Welfare, AFDC, etc.,)(Required)

Number of Persons in Houeshold(Required)

Did your Scout participate in either of the following?(Required)

Fall Popcorn Sale

Spring Sale

Neither

Please describe how your Scout will be earning their portion of the membership fees?(Required)

E-Signature(Required)

First Last

Date(Required)

Month

Day

Year

Consent(Required)

I agree to the privacy policy.

All information contained within this application is considered privileged and confidential. The application must be completed in its entirety, incomplete applications will not be considered. By consenting, you agree all information provided is up to date and accurate.

1340 South Bend Ave.
South Bend, IN 46617
(574) 289-0337
info@lasallecouncilbsa.org

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