Girl Scout Patch Request Form

Patch Request Form
Your Name*

First NameLast Name
Your Email Address*
example@example.com
Your Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Was this program completed by a troop or individual Girl Scout?*

TroopIndividual
Troop Number *
Service Unit*
Your Role*

Troop LeaderOther
Is your troop affiliated with a school?*

YesNo
School Name*
How many Girl Scouts completed the Patch Program and will be receiving patches?*
What level are the Girl Scouts who completed the program (Cadette, Senior, or Ambassador)?*
In what timeframe did you complete the patch requirements?*
Did you visit or utilize resources from a local Holocaust organization?*

YesNo
Which organization?*
Did the Girl Scout(s) watch the required curriculum video or read the transcript?*

YesNo
Did the Girl Scout(s) watch the required curriculum video or read the transcript?*

YesNo
Did the Girl Scout(s) complete the Code Cards activity?*

YesNo
If the Girl Scout(s) completed an additional Connect activity (required for Seniors and Ambassadors), please provide a brief description of the activity.*
Please provide a brief description of the activity completed for the Take Action phase of the program.*
Number of Patches Needed*
Are you able to pick up your patches from the Holocaust Center of Pittsburgh, or do you require shipping?*

Pick-upShipping
Please note that while the program is free, troops must purchase the patches and cover shipping costs.

Cost per patch: $1
Shipping cost within the United States: $6.50
Please contact us for international shipping costs.

A staff member will be in contact with payment instructions.
How would you like to pay for your patches?*

Credit cardCheckInvoice
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Program Feedback
Overall, how would rate your experience with this program?*

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7

1 is Worst, 7 is Best
Would you recommend this patch program to other troop leaders?*

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7

1 is Would not recommend at all, 7 is Would definitely recommend
Did the provided materials make you feel adequately prepared to lead your troop in earning this patch?*

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7

1 is No, I felt completely unprepared, 7 is Yes, I felt very prepared
Please rate how valuable/helpful the following parts of the training were:
Material Warning*

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1 is Not at all helpful, 7 is Very helpful
Leader Guide & Preparation Page*

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1 is Not at all helpful, 7 is Very helpful
Group Agreement*

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1 is Not at all helpful, 7 is Very helpful
Holocaust Education Patch Curriculum Video*

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1 is Not at all valuable, 7 is Very valuable
Discover Activities*

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1 is Not at all valuable, 7 is Very valuable
Connect Activities*

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1 is Not at all valuable, 7 is Very valuable
Take Action Activities*

1

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5

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7

1 is Not at all valuable, 7 is Very valuable
Did your troop utilize any resources from the Holocaust Center of Pittsburgh when earning the patch (e.g. The Crocus Project, field trip, the Generations Speakers Bureau, etc.)?*

YesNo
How easy was it to coordinate with the Holocaust Center?*

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7

1 is Very difficult, 7 is Very easy
How valuable was the Holocaust Center resource(s) to the experience?*

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7

1 is Not at all valuable, 7 is Very valuable
Was this an engaging experience for Girl Scouts?*

Yes, they were highly engaged and interestedSomewhat engaged—some students were interested, others less soNo, they were mostly passive and not very engaged
How did this patch program impact the members of your troop? (Select all that apply)*

Increased their understanding of the HolocaustIncreased their knowledge of Girl Guides during the HolocaustEncouraged empathy and reflectionInspired further discussion or questionsIncreased their pride in being a Girl ScoutDid not have much impactOther
Do you have any other comments about your experience? Did you run into any issues? Was there anything that could have been improved?
Would you be willing to share a quote about your experience that we may use for future materials?
Your quote:
How may we attribute your quote?

Full nameFirst name onlyAnonymous
Optional: Pictures from activities completed from this program.

Cancelof
Does the Holocaust Center of Pittsburgh have permission to use your pictures in future materials (social media posts, website, marketing materials, etc)?

YesYes, but only photos without Girl Scouts' facesNo
Should be Empty: