Volunteer Achievement Award Application

Complete this form and click the submit button at the bottom of this page to email 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 & 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:

Achievement Award Criteria

I am a registered member of the Girl Scouts.
I have completed orientation and training for the award position.
I agree to continue in the award position for one more year (if the award is for a continuing position such as leader, co-leader, service unit team).

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

I have successfully completed one of the following volunteer categories:
       First completed year of troop leadership
           Troop # Date completed Select Date
       First completed year in a Service Unit postion.
           Service Unit Position:
           Date completed Select Date
       First successful completion of a task group assignment.
            Task group name:
            Service Dates Select Date
       First successful completion on a board committee.
           Committee Name:
           Service Date Select Date

Key Awards Criteria-Please check appropriate awards.
See Key Criteria

White Key-Mentor **(if box is checked- must provide additional information in space provided)
    Registered Girl Scout
    List skills you used as a mentor:

    List volunteers you mentored that has/will continue for at least 2 years:
   **(if box is checked- must provide additional information in space provided)
       Name of Volunteer
          Date Volunteer Started Select Date
       Name of Volunteer
          Date Volunteer Started Select Date
       Name of Volunteer
          Date Volunteer Started Select Date
Black Key-Executive **(if box is checked- must provide additional information in space provided)
    Registered Girl Scout
    List the leadership role you served in at the council and the date served:

    List significant contributions to the council:

Gold Key-Diversity **(if box is checked- must provide additional information in space provided)
    Registered Girl Scout
    List ways you have increased membership in underrepresented populations through program delivery, community cultivation and community collaboration:

    List training and enrichment events you took that increased awareness in diversity:

    Give information on something you created that supports the council’s diversity goals:

Silver Key-Community Cultivation **(if box is checked- must provide additional information in space provided)
    Registered Girl Scout
    List ways you increased volunteer membership by using the talents and skills of a diverse community:

    List ways you increased girl membership that is reflective of the council including racial/ethnic, disability, and socioeconomic:

    List ways you have helped with retaining 11-17 year old girls:

    List effective partnerships you established that will help achieve the council’s membership goal:

Copper Key-Fund Development **(if box is checked- must provide additional information in space provided)
    Registered Girl Scout
    List ways you helped reach the council’s fund development goal by increasing financial and/or in-kind resources through grants, corporations/foundations and major gifts:

    List how you increased individual contributions that reflect the diversity of the council through grants, planned giving, annual giving and bequests:

Key Awards Criteria – Please check completed requirements for appropriate award. You will receive a signed voucher 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.

Volunteer Achievement Award Application

Applicant Information

Achievement Award Criteria

Key Awards Criteria-Please check appropriate awards. See Key Criteria

Key Awards Criteria – Please check completed requirements for appropriate award. You will receive a signed voucher in the mail. Please allow 4-6 weeks.

Key Awards Criteria-Please check appropriate awards.
See Key Criteria