Specific Assistance Form

Scout Name

First Name

Last Name

Parent Name

First Name

Last Name

Phone

(###)

###

####

Unit Type

Unit Number

Unit Leader Name

First Name

Last Name

Select What Type of Assistance You Are Requestions

Explain the nature of the financial hardship:

What is the cost of your request?

Registration $55 | Uniform Closet - Enter UC | Event Registration - enter cost of event

Is the Unit providing any cost assistance for this request?

Yes or No, if yes please enter amount here.

Name of Person submitting this request

First Name

Last Name

What is your relationship to the Scout?

Your Phone Number

(###)

###

####

Your Email

In the last year, this Scout participated in the following money earning activities?