Briefly describe your Girl Scout Gold Award Project: ________________________________________________
__________________________________________________________________________________________
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List the name(s) of your local newspaper(s): ______________________________________________________
__________________________________________________________________________________________
If you would like the media release to be submitted to your place of worship or parents’/caregivers’ (in‐house)
employment publication, please list the e‐mail addresses to which it should be sent: _______________________
__________________________________________________________________________________________
I give permission for my daughter’s information to be published in Girl Scout publications.
I give permission for my daughter’s information to be published in local, national, and Girl Scouts of the
USA’s media outlets. (i.e. newspapers, schools, places of worship, etc.)
I DO NOT wish for my daughter’s information to be published.
Family Information
News media often want you to be identified as the "daughter of" or "ward of" named persons. Correct forms
include "Mr. and Mrs. John E. Doe," "Jane and John Doe," or the name of one or the other parent or a guardian.
Please give your preference in the space below. Your signature below will also authorize consent that
photographs of your daughter may be used by Girl Scouts – North Carolina Coastal Pines to publicly recognize
this achievement and promote the Girl Scout program.
__________________________________________________________________________________________
__________________________________________________________________________________________
Date this information given: ________________ Your Signature: ______________________________________
Parent/Caregiver Signature: ___________________________________________________________________
Recognition from Local and National Government Officials and Agencies:
As part of the Girl Scout Gold Award recognition process, Girl Scouts–North Carolina Coastal Pines may inform
local and national government officials and agencies of Girl Scouts who have earned the Girl Scout Gold Award.
Please complete the following to give or deny permission for GS–NCCP to reach out to these organizations on
your Gold Award Girl Scouts’ outstanding accomplishment. Please select from the following:
I, ___________________________(parent/caregiver first and last name) give my permission for Girl Scouts–
North Carolina Coastal Pines to inform national and local government officials and agencies of my girl’s distinction
as a Gold Award Girl Scout. I understand that it is at the organization’s discretion to send the letters and/or
recognitions of her accomplishment and I understand her name and mailing address will be provided so
correspondence can be mailed to her directly.
I, ___________________________(parent/caregiver first and last name) do not give my permission for Girl
Scouts–North Carolina Coastal Pines to inform national and local government officials and agencies of my girl’s
distinction as a Gold Award Girl Scout.
