GSUSA Lifesaving Award Nomination Request Form

GSUSA Lifesaving Award Nomination Request Form

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The National GSUSA Lifesaving Awards were created in 1913 to recognize extraordinary bravery and to honor Girl Scouts whose independent actions were essential to a lifesaving rescue. As such, these awards are reserved only for Girl Scouts who initiated and led lifesaving actions or played a critical leadership role in a large rescue situation.

These awards acknowledge a Girl Scout who has saved or attempted to save human life, with or without risk to their own life, and under circumstances that most persons of their age and life experience would not be able to function.

Bronze Cross - Given for saving a life or attempting to save a life with risk to the candidate's own life.

Medal of Honor - Given for saving a life or attempting to save a life without risk to the candidate's own life.

Girl Scout Rescuer Criteria:
- The Girl Scout must be a registered girl member at the time of the rescue. No award is given to adults.
- A Girl Scout who has caused or contributed to the circumstances necessitating the rescue is automatically ineligible.
- Consideration of the Girl Scout’s interest in recognition is paramount. The acclaim accompanying such an award might be detrimental. If the rescue, or attempted rescue, has been a particularly harrowing experience, it might not be appropriate to give an award. In addition to consulting with the Girl Scout, consulting with parents/caregivers, friends, and teachers could be helpful in making a wise decision about applying for the award and any associated recognition.
Risk to Life Criteria:
- Awards are given for saving, or attempting to save, human life only. Note: A Girl Scout can receive a Lifesaving Award if the person they attempt to rescue does not survive.
- Girl Scout rescuer provided proper first aid and emergency-care procedures to prevent death and reduce further injury.
- The degree of danger to the life of the person(s) being rescued was so great that without the actions taken by the Girl Scout rescuer, death was imminent or a strong possibility.
Girl Scout-Led Action Criteria:

Girl Scout rescuer's independent actions were essential to the rescue in ONE of the following categories where they met most or all of the criteria:

1. Girl Scout Responding Alone
- Girl Scout rescuer became aware of the situation on their own with no input from others except possibly the victim.
- Girl Scout rescuer assessed the situation, determined the level of risk to life, and called for help themselves.
- Girl Scout rescuer alone implemented appropriate rescue technique(s) to physically retrieve and/or stabilize the victim.
- Girl Scout rescuer administered appropriate first aid emergency care procedures.
- Girl Scout rescuer stayed with the victim until victim was under the care of professional emergency responders, the person’s legal guardian, or another trusted adult took personal responsibility for any next steps.
2. Girl Scout Directs Group Members
- Girl Scout rescuer became aware of the situation in the presence of others.
- Girl Scout rescuer assessed the situation, determined the level of risk to life, called for help themselves or directed others to call for assistance.
- Girl Scout rescuer alone implemented appropriate rescue technique(s) to physically retrieve and/or stabilize the victim and/or directed others in the group to implement their stated directions to enact the physical rescue and/or stabilization of the victim.
- Girl Scout rescuer administered appropriate first aid emergency care procedures and/or directed others in the group to implement their stated emergency care directions.
- Girl Scout rescuer stayed with the victim until victim was under the care of professional emergency responders, the person’s legal guardian, or another trusted adult took perpersonal responsibility for any next steps.
3. Girl Scout Responding in Large Rescue Situation
- Girl Scout rescuer became aware of the situation in the presence of others or was called to the situation by others.
- Girl Scout rescuer was assigned by the incident chief (person in charge of handling the emergency) specific tasks to implement as part of the large, complex, rescue situation.
- Girl Scout rescuer assessed the environment for available resources (equipment, other individuals, etc.), created an action plan, and implemented their self-designed course of action, making any adjustments needed to achieve their assigned task(s).
- Girl Scout rescuer may have directed additional individuals to take specific actions as part of the task they were assigned to fulfill.
- Girl Scout rescuer reported their completed actions to the incident chief.
How to Apply:

Girl Scouts of the USA has designed procedures to help councils celebrate and formally recognize these acts of heroism. The application for the Lifesaving Award must be submitted within six months after the incident occurred and must meet the following requirements:
- Give full details of the incident.
- Include a personally signed narrative statement from the rescuer, the rescued person, and up to two different witnesses. (See the Guidelines for Narrative Statements section below.)
- Signed by the nominator.
- Recommended by the council before submission to GSUSA.
The council will review the application, determine whether this was a Girl Scout-led lifesaving effort, and decide to recommend it before submitting the complete application to GSUSA for final approval. GSUSA's National Lifesaving Award Review Committee processes applications monthly.

If the candidate does not meet the Lifesaving Award standards, please contact the council to discuss how the candidate can be honored locally, within the council, service unit, or troop community.
Submission Date:*
MM-DD-YYYY
Rescuer Information:
Girl Scout Rescuer's Name*

Rescuer's First NameRescuer's Last Name
Rescuer's Age*
Rescuer's Grade in School*
Rescuer's Girl Scout Level:*

DaisyBrownieJuniorCadetteSeniorAmbassador
Rescuer's Parent or Caregiver's Name(s): *
Phone Number (if known):
Please enter a valid phone number.
Email (if known):
example@example.com
Rescuer's Troop Number: *
Juliette members please enter "Juliette".
Rescuer's Service Unit Number: *
If unsure, enter the town the nominee resides in.
Nominator Information:
Who Can Submit a Nomination?

Nominations may be submitted by anyone except the nominee herself. This includes GSNYPENN volunteers, council staff, fellow Girl Scouts, and family members. You do not need to be a registered member of GSNYPENN to submit a nomination. Please note: self-nominations are not permitted.
Nominator's Name: *

First NameLast Name
Relationship to Rescuer:*

Troop Leader/VolunteerService Unit VolunteerCouncil RepresentativeRescued PersonParent/CaregiverOther
Nominator's Email Address:*
example@example.com
Nominator's Phone: *
Please enter a valid phone number.
Nominator's Troop Number: *
If not a member of a troop enter N/A.
Nominator's Service Unit Number: *
If unsure, enter the town the nominator resides in.
Information About the Person Rescued (if known):
Rescued Person's Name

First NameLast Name
Relationship, if any, to Girl Scout rescuer:
Approximate Age of Rescued Person:

Infant-Toddler (0-3)Child (4-12)Teenager (13-17)Adult (18+)Senior Adult (65+)
May We Contact Person Rescued?

YesNo
Rescued Person's Email:
example@example.com
Rescued Person's Phone Number:
Please enter a valid phone number.
If multiple persons rescued, please provide details here:
Information About the Rescue:
Date Incident Occurred:*
MM-DD-YYYY
Incident Location:*
Time of Incident:*
Approximate if unknown
Nominator: Please describe the type of incident and the lifesaving actions the Girl Scout rescuer took.

Examples of Lifesaving Aid:
- Performing CPR on someone unconscious or not breathing.
- Using an AED (automated external defibrillator) during a cardiac emergency.
- Stopping severe bleeding using pressure or a tourniquet until help arrives.
- Rescuing someone from drowning in a pool, lake, or other body of water.
- Helping someone escape a fire, car crash, or other dangerous situation.
- Calling 911 and giving critical information while keeping a victim calm and safe.
- Assisting during a medical emergency like a seizure, allergic reaction, or diabetic shock—especially if quick thinking and first aid helped save a life.
- Guiding emergency responders to the scene in a rural or hard-to-find location.
- Staying with an injured person and giving comfort while ensuring they didn’t move and worsen an injury.
These actions typically involve quick thinking, courage, and immediate response, often when professional help has yet to arrive.
Incident Summary: Please provide a 1-2 sentence description of the type of incident and actions taken by the Girl Scout rescuer, such as rendering lifesaving aid (CPR, abdominal thrust) and/or conducting a lifesaving rescue (fall, fire, auto, hiking/outdoor):*
Award the Girl Scout is being nominated for:*

Medal of Honor -This award is given to a Girl Scout who has shown the presence of mind and true Girl Scout spirit saving life or attempting to save life without risk to the candidate’s own life.Bronze Cross - This award is given to a Girl Scout who has shown extraordinary heroism saving life or attempting to save life with risk to the candidate’s own life.
Narrative Statements:
Guidelines for Narrative Statements

Narrative statements from the perspective of the Girl Scout rescuer, the person rescued, and up to two witnesses are required. Other supporting documents are optional.

In some circumstances, narrative statements will either not be available or not appropriate to request from the parties listed above as we recognize there may be a degree of discomfort or traumatization following the incident. If this is the case, and if possible, please provide two statements from a witness and/or responding emergency personnel (examples: 911 dispatch, police, fire, or emergency medical personnel). For the health and safety of those involved, we respect your judgement in determining what statements are appropriate to provide.

Each person writing a narrative statement should, from their own perspective, include the following information to best explain how the rescue occurred and the circumstances surrounding the rescue:
1. Writer’s name and role in the rescue: Girl Scout rescuer, person rescued, witness
2. Description of place where rescue occurred and what happened that required a person(s) to be rescued
3. Description of exact nature of risk to life of person(s) rescued
4. Description of the rescuer’s independent actions (Girl Scout-led) that were essential to the rescue
5. For rescuer only: What, if any, of the skills you used in the rescue did you learn in Girl Scouts? (If none, please say “none”). Note: It is not required that you applied skills learned in Girl Scouts to earn the Lifesaving Award; this is for data collection purposes only
6. Description of extent of good judgement shown by rescuer in performing the rescue
7. Description of exact nature of risk to life of Girl Scout rescuer (if any)
8. Description of weather and its role in rescue (if appropriate)
9. Any effects of the rescue upon the rescuer
10. Any unique factors of the situation or people involved that support the bravery and heroic act of the Girl Scout rescuer
Narrative Statement Format:
- Statements may be handwritten or typed and signed by the statement writer.
- They must be saved as individual documents in the following file naming format and attached to this form:
  1. (Last name, first initial of Girl Scout Rescuer) - Rescuer Statement
  2. (Last name, first initial of Girl Scout Rescuer) - Person Rescued Statement
  3. (Last name, first initial of Girl Scout Rescuer) - Witness Statement
Please upload signed narrative statements as typed or scanned handwritten documents from the rescuer, the rescued, and at least two different witnesses:*

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Supporting Document Format:
- Supporting documents must be saved in electronic format. They may include scanned published newspaper articles, working links to media stories, etc.
- They must be saved as individual documents in the following file naming format and attached to this form: (Last name, first initial of Girl Scout Rescuer) - Supporting document.
Please upload any supporting documents in electronic format:

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Application Acknowledgments
Nominator Acknowledgement:

The foregoing facts and accompanying statement of the rescuer, rescued person, and witnesses are, in my understanding, correct. I believe that the Girl Scout rescuer has met the criteria for earning a GSUSA Lifesaving Award. I understand that if the council validates this application, it will be submitted to Girl Scouts of the USA’s National Lifesaving Review Committee who will determine if/what award is conferred.
Nominator: by entering your name you acknowledge the above statement.*

First NameLast Name
Girl Scout Rescuer and Parent/Caregiver Acknowledgement and Content Release Acknowledgement:

We, the Girl Scout and their parent/caregiver, are aware of and support this Lifesaving Award application.
Girl Scout Rescuer: by entering your name you acknowledge the above statement.*

First NameLast Name
Parent/Caregiver: by entering your name you acknowledge the above statement.*

First NameLast Name
Content Release:

Girl Scouts of the USA (GSUSA) may like to share your name and tell your story. If you check "yes," you will be provided a copy of the GSUSA Lifesaving Award Content Release to review and sign.
Please check the appropriate box:*

Yes, I would like this story to be shared, and I will complete the Lifesaving Award Content Release form as requested.No, I would not like this story shared.
Final Reminders:

Once we receive this form, appropriate council staff will review the supporting documents to determine whether the Girl Scout's rescue qualifies for one of the Lifesaving Awards. Please allow up to 14 business days for this review process.

If additional information is needed, the council may contact you. Prompt responses are appreciated to help keep the process on track.

If award criteria are met, the nominator will be notified, and council staff will submit a council-recommended Lifesaving Award application to GSUSA for consideration.

If you have any questions about this form, the award criteria, or the status of your application, please don't hesitate to contact the council at info@gsnypenn.org or call (800) 943-4414, option 2.
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GSUSA Lifesaving Award Nomination Request Form

Rescuer Information:

Nominator Information:

Information About the Person Rescued (if known):

Information About the Rescue:

Narrative Statements:

Application Acknowledgments