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: 

I give permission to share contact information with other Regional Delegates:   Yes  No

Current Age:  

Years in Girl Scouting:  

Troop #:  

Parent/Guardian: 

Current Grade:  

School:  

Principal's Name:  

School Phone:  

The information in this application 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.)

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