Adult Volunteer Service Record
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1
2A copy of this form should be
NAME: ________________________________
kept on file in the service unit.
Type or use black ink.
DATE: ________________________________
Girl Scouts of San Jacinto Council
ADULT VOLUNTEER SERVICE RECORD
12
Stargazers
Region:
Community:
Month/Year updated:
Address:
Home Phone (
)
City:
Zip Code:
Work Phone (
)
Occupation:
Years registered: Girl
Adult
Other Council
GSSJC
MEMBERSHIP NUMERALS RECEIVED (Please state year received, including girl & adult years):
5 year
25 year
45 year
10 year
30 year
50 year
15 year
35 year
55 year
20 year
40 year
year
YEARS OF SERVICE PINS RECEIVED (Active adult years only, please state year received):
5 year
25 year
45 year
10 year
30 year
50 year
15 year
35 year
55 year
20 year
40 year
year
COUNCIL AWARDS RECEIVED (Please state year received):
Appreciation Pin
__________ Thanks Badge
__________
Thanks Badge II
__________
Honor Pin
__________ Continuing Service
__________
Family Award
__________
Volunteer of Excellence
__________ Other
__________
Lifetime Achievement
__________
COMMUNITY/REGION AWARDS (Please state year received):
Community/Service Unit
Region/District
Outstanding Leadership Team
____________
Outstanding District Volunteer
____________
Outstanding Volunteer
____________
Other _______________________
____________
Outstanding Leader
____________
Other _______________________
____________
Other _______________________
____________
Other _______________________
____________
Other _______________________
____________
Other _______________________
____________
VOLUNTEER SERVICE BEYOND GIRL SCOUTING:
DATE
ORGANIZATION
TYPE OF SERVICE
__________
________________________________________
________________________________________
__________
________________________________________
________________________________________
__________
________________________________________
________________________________________
__________
________________________________________
________________________________________
__________
________________________________________
________________________________________
GSSJC F-122
Rev.7/13 from 7/03
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