GIRL SCOUTS OF THE PHILIPPINES

National Headquarters
Manila

CGSMS Form No. 1

CHIEF GIRL SCOUT MEDAL SCHEME

APPLICATION FORM
I. Personal Information
Name : _As_______________________________________
Address : _________________________________________________________________________________
Telephone / CP No. : ______________________ _________________ Troop No. ________________ ____________
Region : NORTHERN LUZON Council : PANGASINAN
Troop Leader : __________________________________________________________________________________
Registration Dates : ___________________________________________________________________________________
Three (3) Years of Girl Scouting Experience : _ ______________________________________________________________
________________________________________________________________
________________________________________________________________

II. Badgework ( 2 Badges for each of the 8-Point Challenge )

Badges Earned Challenge Dates Earned

1 Well - Being
2 Well - Being
3 Arts
4 Arts
5 Preparedness
6 Preparedness
7 Family Life
8 Family Life
9 Environment
10 Environment
11 Economic Self - Sufficiency
12 Economic Self - Sufficiency
13 Heritage & Citizenship
14 Heritage & Citizenship
15 World Community
16 World Community

III. Camping Record:

Level Encampment Date Venue

Troop
District
Council
Regional
National
International

IV. Chief Girl Scout Medal Scheme Orientation / Workshop:

Date : October 15,2022 Place :

Submitted by : ___________________________ ______________

Name of Candidate

Noted by : ____ __________________________________

Troop Leader

EUFEMIA B. DE GUZMAN
Council Executive

LAILA F. MORALES
Attachments : Regional Executive Director
1. Troop Leader’s Endorsements
2. Parents’ Endorsements
3. Community Profile
Due Date : August 15

COMMUNITY PROFILE

1. Name of Purok / Zone _____________________ Population : ____________________

2. Barangay : ______________________________________________________________
Municipality /Province/City : _________________________________________________
3. No. of Families in the Purok : ________________ No. Interviewed : _________________
4. No. of Houses: ___________ Light material : ____________ Concrete :____________
5. No. of Houses with :Toilets : ________________ Electricity : _________________
Running Water : ___________ Deep Well : _________________
Flower Gardens : __________ Vegetable Gardens : ___________
Poultry : __________________ Piggery : ____________________
Others ( Specify ) _________________________________________
6. No. of School/s in the Purok / Zone : _________________________________________
7. No. of Church/Chapel in the Purok / Zone : ____________________________________
8. No. of Government offices located in the Purok / Zone : __________________________
9. No. of Hospital / Clinic in the Purok / Zone : ____________________________________
10. Community Centers available like Day Care, Reading, Health Center, others ( Specify ) in
the Purok / Zone __________________________________________________________
11. Means of transportation available in the Purok /Zone : ____________________________
_______________________________________________________________________
12. Recreational facilities are available : __________________________________________
________________________________________________________________________
13. Means of livelihood/occupations/employment of the people in the Purok/Zone__________
_______________________________________________________________________
14. Educational attainment of the : ( Indicate Number )
Men ( Elementary , High School ) : _____________________________________
Women ( Elementary , High School ) : _____________________________________
15. No. of School Children of School Age ( 6 Years – 21 Years )
In - School : _____________________ Out – of -School : ____________________
16. General conditions of : Roads : _____________ Drainage : _____________________
Park / Plaza : ______________ Playground : ________________
Market : _____________ Garbage Disposal : ________________
Trees & Other Plants : __________________________________
17. Person/s Interviewed : ____________________________________________________
____________________________________________________
____________________________________________________
18. Identified Three ( 3 ) Community Problem/Needs :
a. ________________________________
b. ________________________________
c. ________________________________

_________________________________
Chief Girl Scout Medal Candidate

_________________________________
Date
Noted By:

________________________________
Troop Leader