Part I: Senior Girl Scout Gold Award Application

Please type or write legibly in black ink.  When the information is complete, make copies for your Leader and yourself.  Mail the completed application to the Girl Scouts – Mile Hi Council Program Center, ATTN: Gold Award Staff Advisor, 400 South Broadway, P. O. Box 9407, Denver, CO 80209-0407 six weeks prior to the time you plan to interview with the Gold Award Committee.
	
After downloading this application to a Microsoft Word document on your computer, insert the requested information in the shaded areas and tab to the next field.  As you will note the shaded areas will expand to fit the space you need.

Each answer should contain complete sentences.

Name:         		Phone:        
Email Address:        

Address:        
City:        	Zip:        

Birthday:         	Grade:      	Name of School:        

Name of Leader      				Leader’s Phone Number:        
Troop Number      	 			Service Number      

Did you earn your Silver Award?  Yes         No         
If yes, was it an individual or group project?      
If yes, what was your project?        

Have you attended Silver and Gold Award Info Night hosted by Mile Hi Council? Yes        No        

What month/year did you become a Senior Girl Scout.?       
Year of High School Graduation       

Title of your Gold Award Proposed Project:        

Date Proposal Submitted:        

Anticipated Start Date:        		Anticipated Completion Date:        

      Part II: Requirements 1 through 4

Name________________

1. Interest Projects Earned	Month / Year Completed	Leader/Advisor Signature 

	       	            	_________________________

	       	            	_________________________

	       	            	_________________________

	       	            	_________________________

2. Career Exploration Pin
    Briefly describe the option completed:        

					Month / Year Completed	Leader/Advisor Signature

	  	       	_________________________

3. Senior Girl Scout Leadership 	
    Award Activities 				Month / Year Completed	Leader/Advisor Signature

	       	            	_________________________

	       	            	_________________________

	       	           	_________________________

	       	         	_________________________

4. Girl Scout Challenge 			Month / Year Completed	Leader/Advisor Signature

    Section 1:        	            	_________________________
    
    Section 2:        	            	_________________________

    Section 3:        	            	_________________________

    Section 4:        	            	_________________________

    Section 5:        	            	_________________________
(Indicate with an asterisk (*) the Section that taught you the most.)
               Part III: Girl Scout Gold Award Proposed Service Project

Name        

Title of Gold Award Service Project:         

Explain your Gold Award service project.        

a.	Who are you helping?        

	b.	How will this project help your community?        

c.	List the steps required to put your project into action. Include the estimated time to complete each step and the cost, if applicable.

Steps	
Hours	Cost
(if applicable)	
i.           

	     	     	
ii.         

	     	     	
iii.        

	     	     	
iv.        

	     	     	
v.         

	     	     	
vi.        

	       	       	
vii.       

	       	       	
Total	       	       	

d.	List the resources you will need. For example, professional consultants related to your project, equipment, places, information sources and supplies.    
						            
		      

e.	How will you measure the success of your project? For example, how many coats will you collect or how many people will you teach, etc.    

	                  

f.	If your project is to continue after you have earned your Gold Award, please explain how it will be sustained or maintained. For example, will you prepare an instruction booklet?    

	                  

1.	 	How will this project allow you to use your leadership skills?    

	      

2.	Outline the strengths, talents and skills that you will use to complete this project.    

	      

3.	How does this project challenge you?    

	      

4.	What do you hope to learn, or how will you grow, from this project?

	      

Part IV: Girl Scout Gold Award Proposed Plan Signatures

Title of Gold Award Proposed Project        

Your Signature ___________________________________________________Date: _____________

To the Leader Advisor:  I have carefully reviewed this application and any attachments for completeness, clarity and accuracy and have discussed the important points with the applicant.  I understand that the applicant will be assigned a Gold Award Liaison to oversee / assist in the implementation of the Gold Award Project.

Leader/Advisor Signature ___________________________________________Date: _____________

For Official Use Only

Date Received

	Registered Girl Scout?	Date Reviewed	Status	
Date of Pre-Interview Letter/Call

	Date of Initial Interview	Liaison	Date Liaison Letter Sent	
Date(s) of Project Events

	Date Donation Letter Sent	Date of Final Evaluation	Status