GIRL SCOUTS OF THE PHILIPPINES

National Headquarters 2” x 2”
Manila
Photo
GGSMS Form No. 1

CHIEF GIRL SCOUT MEDAL SCHEME

APPLICATION FORM

I. Personal Information
Name : _________________________________________________________________________
Address : _________________________________________________________________________
Telephone No. : ______________________________ Troop Number :__________________________
Region : ___________________________________ Council : __________________________
Troop Leader : _________________________________________________________________________
Parents : _________________________________________________________________________
Occupation : _________________________________________________________________________
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. ________________________ ____________________________ _______________________
2. ________________________ ____________________________ _______________________
3. ________________________ ____________________________ _______________________
4. ________________________ ____________________________ _______________________
5. ________________________ ____________________________ _______________________
6. ________________________ ____________________________ _______________________
7. ________________________ ____________________________ _______________________
8. ________________________ ____________________________ _______________________
9. ________________________ ____________________________ _______________________
10. ________________________ ____________________________ _______________________
11. ________________________ ____________________________ _______________________
12. ________________________ ____________________________ _______________________
13. ________________________ ____________________________ _______________________
14. ________________________ ____________________________ _______________________
15. ________________________ ____________________________ _______________________
16. ________________________ ____________________________ _______________________
III. Camping Record
Encampment Date Place
Troop : _____________________ ______________________ ______________________________
District : _____________________ ______________________ ______________________________
Council : _____________________ ______________________ ______________________________
Regional : _____________________ ______________________ ______________________________
National : _____________________ ______________________ ______________________________
IV. Chief Girl Scout Medal Orientation/Workshop
Date: ________________________________ Place: _________________________________________

Submitted by: ____________________________________

Name of Candidate

Noted by: ____________________________________

Troop Leader
Attachments:
1. Troop Leader’s Endorsement ____________________________________
2. Parents’ Endorsements
Council Executive
3. Community Profile
____________________________________
Regional Executive Director
 CGSMS Form No. 1-A
COMMUNITY PROFILE

1. Name of Purok/Zone: _________________________________ Population: _____________________

2. Barangay: __________________________________________________________________________
Municipality/Province/City: ____________________________________________________________
3. No. of Families in the Purok: __________ No. Interviewed: __________ No. of Houses: ____________
4. No. of Houses: ______________ Light Material: ________________ Concrete: _________________
5. No. of Houses with:
Toilets : __________________ Flower Gardens : __________________
Electricity : __________________ Vegetable Gardens : __________________
Running water : __________________ Poultry : __________________
Artesian Well : __________________ Others (specify) : __________________

6. Number of Schools in the Purok/Zone: ___________________________________________________

7. Number of Church/Chapel in the Purok/Zone: _____________________________________________
8. Government Offices located in the Purok/Zone: ____________________________________________
___________________________________________________________________________________
9. Number of Hospital/Clinic in the Purok/Zone: ______________________________________________
10. Community Centers available like Day Care, Reading, Health, others (specify) in the Purok/Zone:
__________________________________________________________________________________
11. Means of transportation available in the Purok/Zone: ______________________________________
12. Recreational facilities available in the Purok/Zone: _________________________________________
__________________________________________________________________________________
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. Number of school children of school age (6 yrs. - 21 yrs.):
In-school: ______________________________________________________________________
Out-of-school: __________________________________________________________________
16. General conditions of:
Roads : __________________________ Playground for children: __________________
Drainage : __________________________ Market : __________________
Park/Plaza : __________________________ Garbage disposal : __________________
Trees and other plants: _________________
17. Person/s Interviewed: _______________________________________________________________
18. Identified Three (3) Community Problems/Needs
a. ________________________________________________________________________________
b. ________________________________________________________________________________
c. ________________________________________________________________________________

________________________________
Chief Girl Scout Medal Candidate

________________________________
Date of Survey

Noted:

___________________________
Troop Leader

GIRL SCOUTS OF THE PHILIPPINES

 NATIONAL HEADQUARTERS
MANILA
CGSMS Form No. 2
CHIEF GIRL SCOUT MEDAL SCHEME
PHASE 1 REPORT due EO September
Name : ________________________________________________________________________
Address : ________________________________________________________________________
Telephone No. : ____________________________ Troop No. _________________________________
Council : ____________________________ Region: ___________________________________
Troop Leader : ________________________________________________________________________
Target Community : ________________________________________________________________________
1. From the community problems/needs surveyed select only one most pressing as recommended by the community for
your project:
__________________________________________________________________________________________________
2. Area of Work (one only): ____________________________________________________________________________
3. Badgework
Related Badges Earned Dates Earned

1. _________________________________________________ ____________________________
2. _________________________________________________ ____________________________
3. _________________________________________________ ____________________________
4. _________________________________________________ ____________________________
5. _________________________________________________ ____________________________
6. _________________________________________________ ____________________________
7. _________________________________________________ ____________________________
8. _________________________________________________ ____________________________
9. _________________________________________________ ____________________________
10. _________________________________________________ ____________________________
11. _________________________________________________ ____________________________
12. _________________________________________________ ____________________________
13. _________________________________________________ ____________________________
14. _________________________________________________ ____________________________
15. _________________________________________________ ____________________________
16. _________________________________________________ ____________________________
4. About the Project (use extra sheets)
4.1 Project Description _____________________________ 4.4 Time Table ______________________
4.2 Objectives ____________________________________ 4.5 Budget __________________________
4.3 Methods ______________________________________
5. Name of Consultant/s beside the TL. (Those who provide Technical support to guide in objectives formulation and
congruency of activities to the objectives)
5.1 ________________________________________ 5.3 _______________________________________
5.2 ________________________________________ 5.4 _______________________________________
6. Names of Work Group (Prospective CGSMS candidates but not those working already) SKs and other adults
6.1 ________________________________________` 6.5 _______________________________________
6.2 ________________________________________ 6.6 _______________________________________
6.3 ________________________________________ 6.7 _______________________________________
6.4 ________________________________________ 6.8 _______________________________________
7. References (Attach list of titles/topics related to the Project – (at least 3)
Name of Book Topic/Title Read
7.1 ________________________________________ ___________________________________________
7.2 ________________________________________ ___________________________________________
7.3 ________________________________________ ___________________________________________
8. From your readings in No. 7 how did you apply the learning's or insights gained in your project? (use extra sheet/s)

Noted by: Submitted by:

_________________________________________ __________________________________________
Troop Leader Candidate

_________________________________________ ___________________________
Council Executive Date

_________________________________________
Regional Executive Director
 GIRL SCOUTS OF THE PHILIPPINES
NATIONAL HEADQUARTERS
MANILA

CGSMS Form No. 3

CHIEF GIRL SCOUT MEDAL SCHEME

PHASE 2 REPORT EO October

Name : __________________________________________________________________________________________

Council : ____________________________________________ Region: ___________________________________

Troop No.: __________________________ Troop Leader: _________________________________________________

1. Self Development Skills Acquired and Practiced (at least 3 useful skills)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

2. Spiritual Readings (How did you apply the learnings gained from your spiritual readings in your project? – at least 5)

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

3. Spiritual Adviser/s

Name/s Dates of Counselling

_______________________________________________ ___________________________________________
_______________________________________________ ___________________________________________
_______________________________________________ ___________________________________________

4. Networking (List the names of Agencies/Organizations networked with)

_______________________________________________ ___________________________________________
_______________________________________________ ___________________________________________
_______________________________________________ ___________________________________________

Submitted by:

____________________________________________
Candidate
Noted by:

___________________________________________
Troop Leader _______________________
Date

___________________________________________
Council Executive

___________________________________________
Regional Executive Director
 GIRL SCOUTS OF THE PHILIPPINES
NATIONAL HEADQUARTERS
MANILA

CGSMS Form No. 4

CHIEF GIRL SCOUT MEDAL SCHEME

PHASE 3 IMPLEMENTATION REPORT – EO May

Name : __________________________________________________________________________________________
Council : ___________________________________________ Region: ____________________________________
Troop No.: _____________________________ Troop Leader: ______________________________________________

1. Work Done Dates Activities Undertaken Persons Involved

(use separate sheets)
____________________ ______________ ___________________________ ________________
____________________ ______________ ___________________________ ________________
____________________ ______________ ___________________________ ________________

2. Meetings with:
Dates of Meeting Results (attach Minutes of Meetings)
Purok Leader ________________ _____________________________________________________

Work Group with ________________ _____________________________________________________

Troop Leader

Monitoring Panel 1. ________________ _____________________________________________________

2. ________________ _____________________________________________________
3. ________________ _____________________________________________________

Others (specify): ________________ _____________________________________________________

3. Date of visits of the monitoring panel

3.1 _______________________________________________ 3.2 _____________________________________

4. Observations of the monitoring panel (attach copies of observations)

Submitted by:

__________________________________________
Candidate

_______________________________
Date

Noted by:

_______________________________________
Troop Leader

_______________________________________
Council Executive
 _______________________________________
Regional Executive Director

Girl Scouts of the Philippines

NATIONAL HEADQUARTERS
MANILA

CGSMS Form No. 5

CHIEF GIRL SCOUT MEDAL SCHEME

ACCOMPLISHMENT REPORT- EO June

Name : _________________________________________________________________
Council : _____________________________ Region: _________________
Troop No : ___________________ Troop Leader: _________________

1. Summary of the Project

1.1 Narrative Report of Accomplishment (use extra sheets as needed)
1.2 Effects on the :
Community
__________________________________________________________________
__________________________________________________________________

Candidate
__________________________________________________________________
__________________________________________________________________
2. Turn over ceremony ( attached copy of the program)
Place ____________________________________________________________
Date ____________________________________________________________
3. List of Persons recognized/appreciated Assistance Received
(use extra sheets)
_________________________________ ______________________________
_________________________________ ______________________________
4. Plans for Sustaining the Project
_____________________________________________________________________________
_____________________________________________________________________________

Submitted by:
__________________________________________
Candidate
______________________________
Date
Noted by:
____________________________________
Troop Leader

_____________________________________
Council Executive
 _____________________________________
Regional Executive Director

GIRL SCOUTS OF THE PHILIPPINES

National Headquarters
Manila
CGSMS Form No. 6
CHIEF GIRL SCOUT MEDAL SCHEME
EVALUATION FORM

Name : _______________________________________________________________________
Council : __________________________ Region: ______________________________________
Troop No. : __________________________ Troop Leader: ________________________________
Area of Work : _______________________________________________________________________
Period Covered : From _______________________________ To ________________________________

CRITERIA FOR EVALUATION

I. Personal Attribute - 30%(to be rated by the Troop Leader) Rating
Adequate progress and growth in:
a. Spiritual and Physical Health
b. Integrity
c. Sense of Responsibility
d. Perseverance, Effort, Determination
e. Manners and Decorum
f. Knowledge and Skills
g. Poise and Grooming
Name and Signature of Troop Leader ________________________________
Signature over Printed Name
II. Performance - 40% (to be rated by the Panel of Evaluators) Rating
a. Leadership abilities
- Planning
- Organizing
b. Implementation
- Follow through of plans
- Networking
- Use of resources
c. Documentation
- completeness of records (neatness, organization and presentation of
thoughts, presence of required documents)
III. The Project (30%)
a. Community Involvement
b. Effect on:
- the community
- the candidate
c. Sustainability
TOTAL
REMARKS
Note: A percentage of 80-100% qualifies the candidate’s project to be submitted to GSP-NHQ.

Evaluated by:
____________________________
_______________
Position
Noted by:
________________________ ________________
Regional Executive Director Date

Note: to be enclosed in the Final Ratings

 GIRL SCOUTS OF THE PHILIPPINES
National Headquarters
Manila

CGSMS Form No. 7

CHIEF GIRL SCOUT MEDAL SCHEME

SUMMARY OF RATINGS

Name : _______________________________________________________________________

Council : _____________________________ Region: ___________________________________

Troop Leader : _____________________________ Troop Number: ____________________________

Area of Work : _______________________________________________________________________

NAME OF EVALUATOR POSITION SIGNATURE RATING

1. Council Commissioner on Program
2. Council Executive
3. Outstanding Citizen
4. Outstanding Citizen
5. Regional Representative
AVERAGE

Prepared by:

___________________________________

__________________________________
Position
Noted by:

_______________________
Regional Executive Director
GIRL SCOUTS OF THE PHILIPPINES
National Headquarters
Manila
 CHIEF GIRL SCOUT MEDAL SCHEME

Name
Family Name
Middle Initial
Region
Council by:
Submitted
Troop Number
Troop Name
Troop Leader
Parents
Ecology
Project Livelihood
(Please check) Health
Cultural
Heritage
Date of Project Started
Project Site
Workgroup
Children
No. of Beneficiaries Families
Others

______________________
Summary of the Project to show the different stages of the project implementation:

Pre-planning:

Planning:

CGSMS Applicant

Implementation:

Turning over of projects to the community leaders:

Endorsed by:

_____________________________________
Council Executive
Noted:

_____________________________________
Regional Executive Director

GIRL SCOUTS OF THE PHILIPPINES

National Headquarters
Manila

CHIEF GIRL SCOUT MEDAL SCHEME

Monthly Project Report

Name : Troop No. :

Council : Troop Leader:
Project :
Year Month Accomplishment Remarks
July

August

2019
September

October

November

December

January

February
2020 March

April

May

June