Name: 

Region (refer to map of regions PDF):  Select One Region 1: South Region 2: West Region 3: East Region 4: North     Service Unit: 

Street address: 

City:      State:      ZIP: 

Home/Cell Phone: 

Email: 

Current Age:  

Years in Girl Scouting:  

Troop #:  

Parent/Guardian: 

Current Grade:  

School:  

Principal's Name:  

School Phone:  

The information in this nomination form will be used for biographical information on the ballots, planning for training, development of regional meeting agenda and priorities, and to help inform the future work of the governance committee. Thank you!

Self-Assessment

Able to be objective, representing the best interests of the Girl Scout Movement, not just a particular geographic area or program level
   Definitely  Somewhat  Limited

Understand the role of Governance in the organization
   Definitely  Somewhat  Limited

Able to participate as a member of a team
   Definitely  Somewhat  Limited

Able to speak in front of small and large groups
   Definitely  Somewhat  Limited

Willing to attend service unit or neighborhood meetings
   Definitely  Somewhat  Limited

Why are you interested in being a regional delegate?

Please list your present/past experiences in Girl Scouting (give details, where possible, i.e. dates, leadership positions, special projects, etc.)

Have you ever attended a council annual meeting, area or regional meeting? Yes No
If yes, as a:  Delegate Alternate Other

What other current activities do you do outside of Girl Scouts? (School, clubs, religious organization; include leadership positions, volunteer hours, years involved etc.)

What special qualities or particular experiences, knowledge, and/or skills will you bring to the role of regional delegate? (e.g. representative for an school, religious or civic organization, board member, policy development, communications, etc.)

Describe a situation when you spoke in support or opposition to an issue being discussed by a group of decision makers. Did you influence the outcome of the decision? Why or why not?

What ideas do you have for communicating within your region to towns, cities, and service units? How might you get other girls interested?

By clicking "Send", I certify that I have read the position description (PDF) for GSEM Regional Delegate. If elected, I am willing to serve as a delegate or alternate and I able to fulfill all the duties listed