Juliette Fund Request

Girl Scout Name

First NameLast Name

Caregiver Name

First NameLast Name

Caregiver Email

example@example.com

Caregiver Phone Number

Please enter a valid phone number.

I am requesting to use my girl's Gateway Green to: Select all that apply

Date of Program Event or Camp

Name if Program Event (if applicable)

Name if Camp session (if applicable)

Name of GS Destination Trip (if applicable)

Link to Program Event or Camp registration page

List any information needed to be include on registration form (emergency contact, food/medical allergies, etc.)

If using Gateway Green for shop purchase, list items below:

Have questions? Contact the Customer Care Team at 877.764.5237 or by email at customercare@gsgateway.org

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