2025 Fall Product Juliette Agreement & Permission Form

2025 Fall Product Program

Juliette Product Program Agreement and Permission Slip
Juliette Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent/Caregiver Name*

First NameLast Name
Best Contact Phone Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Caregiver is a 2026 registered member of the Girl Scouts of Eastern MA (all parent/caregivers must be a registered member in order for Girl Scout to accept paper orders or girl delivery)*

YesNoIn the process of registering
The parent/caregiver has a current, approved GSEMA CORI (all parent/caregivers must have an approved GSEMA CORI that is valid throughout the Fall Program in order to collect money from customers during the Fall Product Program).*

YesNoIn the process of completing CORICORI has been submitted to council
My Juliette will be participating with a troop during the Fall Program.
Please provide troop number here
Junior, Cadette, Senior and Ambassador Juliette's may choose to opt-out of the rewards program and earn an additional $0.05 per earnings level (see Juliette Guide for details). Check below if your Juliette would like to participate in the opt-out option.

Yes! My Juliette would like to opt out.
In the absence of a designated Service Unit Fall Product Mentor for the service unit/town, please indicate the preferred council service center for product/reward pickup*

AndoverWalthamMiddleboroNone of the above - my Juliette opted-out
Has your Juliette submitted a Gold Award project proposal and would like to apply earned funds (Program Credits) toward funding their project?*

YESNO
I understand that in signing this form, I affirm that the information I have given is true, complete and correct.
Parent/Caregiver Signature*

Clear
Should be Empty:

2025 Fall Product Program