Submit this final application after completing all requirements by HC121104093010

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									                                    GSCNC SILVER TREFOIL AWARD
                                        FINAL REPORT FORM


Submit this final report after completing all requirements. This report must be submitted to the Cadette /
Senior Program Specialist, 4301 Connecticut Ave. NW, Washington, DC 20008 by April 1st , or the
first working day after that if the 1st falls on a weekend or holiday, for the girl to be recognized at the
council's recognition ceremony that spring.

Please type or print legibly in black ink.
 Name:                                                                         Girl Scout ID #:
 Street:
 City:                                                  State:                    Zip Code:
 Phone:                                    Assn #                SU #                 Troop #
 Current Grade:                                            Class of:
              Complete the following chart of your service. Attach additional pages if necessary.

INTERNATIONAL CATEGORY (25 Hours)

Month/Year of Service       # of hours                           Brief explanation of service




GOVERNMENT CATEGORY ( 25 Hours of which 15 must be Federal Government)

Month/Year of Service         # of hours                         Brief explanation of service




        GIRL SCOUT COUNCIL OF THE NATION’S CAPITAL CATEGORY
Form Expires April 1, 2012            47
              (50 Hours of which 10 must be with the Council)

          Month / Year of Service    # of hours                 Brief explanation of service




        Briefly explain what you learned as a result of your service in one of the three categories.




       _______________________________________                       _____________________

      Signature of Applicant                                         Date

      ________________________________________                      _____________________

      Signature of Senior/Ambassador Advisor                                      Date


       Date Mailed to GSCNC ___________                         [ ] I have kept a copy for my records




Form Expires April 1, 2012                          47

								
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