Application for Girl Scout Life Saving Awards
Information about the Girl Scout Rescuer:
Girl Name
First Name
Last Name
Age
Grade in School
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Caregiver Name
First Name
Last Name
Phone Number (if known)
Please enter a valid phone number.
Format: (000) 000-0000.
Email (if known)
example@example.com
Information about the nominator:
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to rescuer:
Please Select
Troop Leader/Volunteer
Council Representative/Staff
Parent/Caregiver
Service Unit Volunteer
Rescued Person
Other
Information about the person rescued (if known)
Name
First Name
Last Name
Relationship, if any, to Girl Scout rescuer:
Approximate Age
Please Select
Infant-Toddler (0-3)
Child (4-12)
Teenager (1-17)
Adult (18+)
Senior Adult (65+)
May we contact the person rescued?
Yes
No
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Information about the rescue:
Incident Location:
Date of the incident:
-
Month
-
Day
Year
Date
Time of incident
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).
Submit
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