WellCare/United Healthcare Uniform Order Form
Please use this form to place an order for your uniform or earned awards that can be purchased with the medicaid stipend. This stipend is worth $25 per girl per year. Please note that the uniform you are selecting may cost more than $25 and payment for the balance due will be required.
Your Name
*
First Name
Last Name
Your Relationship to Girl(s) Requesting Uniform
*
Parent/Caregiver
Troop Leader
Other
Please indicate how you would like to receive the uniform.
*
I will pick it up at the Louisville shop.
I would like it mailed to me.
Shipping Address for Order
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number for Order Questions
*
-
Area Code
Phone Number
Phone Number for Payment Due (if different)
-
Area Code
Phone Number
My Girl Scout's Medicaid is through:
*
United Healthcare
WellCare
Uniform Details
Please provide the uniform details for each girl below. You will need to indicate the type of uniform and size (tunic, vest, or sash) and the troop number for each girl.
Daisy Girl Scout Uniform - Grades K-1
Brownie Girl Scout Uniform - Grades 2-3
Junior Girl Scout Uniform - Grades 4-5
Cadette, Senior, or Ambassador Girl Scout Uniform - Grades 6-12
Earned Award Details
You may also use the uniform stipend to pay for earned awards (petals, badges, or pins) for the girls. You will need to know their grade level and the name of the award per girl.
Earned Awards
Please use the box below for any questions or clarifications.
Submit
Should be Empty: