Leadership Development Application

Complete this form and click the submit button at the bottom of this page to email this form to: Recognitions@GSEIWI.org. You can also fill it out, print it, and give to your local Recognition Coordinator, Regional Membership Manager or mail to:

ATTN: Council Recognition Committee,
Girl Scouts of Eastern Iowa and Western Illinois,
2011 Second Avenue,
Rock Island, IL, 61201.

Award is purchased by the individual or service unit/troop. Application must be received by March 1 to be honored at a local event.

Applicant Information

** Means manditory information- you must fill in that field.

**Name of Applicant
Troop # Service Unit #
**Street Address (include apt #)
**City **State **Zip
email Address
**Phone (day) **Phone (evening)
GSEIWI Position for the Award:
School you are associated with:

Leadership Development Pin Criteria Checklist

**(if box(es) are checked- must provide additional information in space provided)

I am a registered member of Girl Scouts.
I have completed one year as a troop leader, co-leader, or group coordinator.
I have completed Orientation, Getting Started and Leadership Essentials (or demonstrated competence)**(if box is checked- must provide date in space provided)
    Date (s) Select Date
I have completed First Aid and CPR **(if box is checked- must provide additional information in space provided)
    Resource person name (if not yourself)
    Date (s) Select Date
I have completed Troop Camp Certification (may be eliminated if the troop does not participate in outdoor activities) **(if box is checked- must provide additional information in space provided)
    Name (if other than yourself)
    Date (s) Select Date
I have participated in at least 2 meetings or events beyond my troop: **(if box is checked- must provide additional information in space provided)
    1. Type of Meeting:
    Location:
    Date: Select Date
    2. Type of Meeting:
    Location:
    Date: Select Date

Leadership Development Leaves

The Leadership Development Leaves recognize additional training that the leader has completed since earning the Leadership Development Pin. Training used to fulfill the requirements for the Leadership Developement Pin do not apply toward the leaves.

Green Leaf= 10 hours of training Silver Leaf= 50 hours of training
Gold Leaf= 250 hours of training

**(if you have completed training (s)- you must provide additional information in space provided)

Training
Hours or CEU's Date Select Date
How has this training improved your work with girls?

Training
Hours or CEU's Date Select Date
How has this training improved your work with girls?

Training
Hours or CEU's Date Select Date
How has this training improved your work with girls?

Training
Hours or CEU's Date Select Date
How has this training improved your work with girls?

You will receive a signed vouched in the mail. Please allow 4-6 weeks.

If you would like to print or save a copy for yourself, you must do so before submitting.
Click on the printer icon on the top right of your webpage to print or go to file and save as.

Press the submit button to email your application.
Please review your information before submitting.