Gold AwardGirl Scout Gold Award Recognition Form

This information is used to write Gold Award Recipient biographies for the Girl Scout Achievement Ceremony and request official commendations. Please answer each of the following questions.

Type or print legibly. Print your name as you want it to appear on official documents.

First Name Middle Initial

Last Name

Address E-Mail Phone

City State 9 digit Zip Code

How many years have you been a Girl Scout? Troop # Service Unit #

Where does your troop meet? (name of site and city) Troop Leader’s name

Parent or Guardians names (first and last)

Do we have permission to give your daughter’s name to reporters? YES NO

Do we have permission to give your daughter’s address to governmental officials so that we can order official certificates of commendation?

YES NO

Parent /Guardian Signature Date

Briefly describe what you have gained from your Girl Scout experience.

What are your career goals?

If attending school or entering the military indicate where or what Branch:

The following information is used to request official commendations of your behalf.

Name of high school you attend or attended College you will attend in the fall

Mailing Address Mailing Address

Principal Name College President’s Name

Information about where you live or lived when you earned the Award

County Name of Township, town, or municipality

Their office's mailing address

Please list names of your elected officials:

PA State Representative US Representative

PA State Senator US Senator

What awards or leadership positions have you held in Girl Scouts?

Bronze Award Silver Award GSEP Scholarships Union League Good Citizenship

Award Girl Delegate to the Council

GSEP Board Girl Delegate Take the Lead Presenter Take the Lead Emcee Names of Religious Award:

_______________________ Service to Girl Scouting Bar Community Service Bar

CIT CIT II Camp Intern VIT LIA Program Aide

Other:

Gold AwardGirl Scout Gold Award Recognition Form

Please list any awards or achievements you earned or leadership positions you held, plus extracurricular activities through your community, school or religious institution from 9th – 12th grades. You can attach a list of activities.