President S Volunteer Service Award Order Form

Girl Scouts, Hornets’ Nest Council 7007 Idlewild Road, Charlotte, NC 28212 (704) 731-6500, Outside Mecklenburg: (800) 868-0528, Fax: 704-567-0598, Website: www.hngirlscouts.org

President’s Volunteer Service Award Order Form

REQUIREMENTS: 1) Recipient(s) must be a United States citizen or a lawfully admitted permanent resident of the United States. 2) Awards are issued for service hours served within a 12-month time period or over the course of a lifetime. 3) Awards are issued for volunteer service only; additional levels of participation with the organization (i.e., charitable support) are not a factor considered for the award. 4) Court-ordered community service does not qualify for the award. 5) Focus areas include: Education, Healthy futures, Environmental stewardship, Veterans and military families, Economic opportunity, Disaster services, or Other

Hours by Award Bronze Silver Gold Kids (5-10) 26 – 49 50 – 74 75 + Teens (11–15) 50 – 74 75 – 99 100 + Young Adults (16-25) 100 – 174 175 – 249 250 + Adults (26 and older) 100 – 249 250 – 499 500+ Families and Groups (Two or more people, with each member contributing at least 25 hours toward the 200 – 499 500 – 999 1,000+ total) President’s Lifetime Achievement Award: Individuals who have completed 4,000 or more hours in their lifetime

FIRST NAME LAST NAME AGE GROUP HOURS SERVED FOCUS AREA PRINT YEAR OF SERVICE FOCUS AREA Carefully check No changes can be made Enter: Kids (5-10), Teens Numbers only Education, Healthy futures, Enter Yes or Format: yyyy names. once order has been placed. (11–15), Young Adults Environmental stewardship, Veterans No (if “other” (This is the year that will (16-25) or Adults (26 and and military families, Economic is listed as be printed on the older). Do not enter the opportunity, Disaster services or focus are, certificate) age range; type only Other. (Do not create your own focus consider the group name area.) entering “No”

NAME OF PERSON COMPLETING DATE OF DAY CELLPHONE SHIPPING ADDRESS – CANNOT BE A PO BOX FORM BIRTH PHONE (must be 18 or older) (XX/XX/XXXX) I agree that by submitting this form that all listed requirements are satisfied, and that I am 18 years or older.

I have attached a log of hours (includes dates of service, # of hours for each date, volunteer service performed on each date, and total # hours). Signature: Date Awards Packages  Prices do not include shipping and handling fees. Shipping and handling charges are calculated in real time and depend on various factors.  Shipping may take several weeks.  Send completed form to GSHNC, 7007 Idlewild Road, Charlotte, NC 28212, Attn: Program Department, President’s Volunteer Service Award. Complete Package

Complete package includes: Customized certificate Choice of pin, medallion, or coin Letter from the President

Pin package - $6.25

Coin package - $8.50

Medallion package - $10.50

Certificate Package

Certificate package includes: Customized certificate Letter from the President

$5.00 $

Pin, Medallion, & Coin Pieces

Pin - $3.00

Coin - $5.00

Medallion - $7.00

Lifetime Pin - $4.00

Lifetime Coin - $6.00

Lifetime Achievement

Certificate package includes:

Enlarged, personalized certificate signed by the President Letter from the President Or, choose Complete Package with pin or Lifetime Coin Cost:

Certificate package - 6.25

Complete package with pin - $7.50

Complete package with coin - $9.25

Total Cost of Awards Selected

Payment must be made by credit/debit card.

Please indicate the best way to reach you during business hours and the best phone number. You will be contacted for your credit card payment over the phone.

Be prepared to pay for the total cost of awards selected, plus around $20 extra for shipping and handling fees. Shipping & Handling

Total Cost