Golden Trefoil Application - Juliette
form #134b • 10/20 • page 1 of 3
The Golden Trefoil program denotes excellence throughout an entire membership
year. Use this form to help your Juliette track their progress. Please have your Juliette
complete the form and follow the instructions on the third page to receive the Golden
Trefoil patch. Find the Golden Trefoil Application for troops (#134a) here.
Name__________________________________________________________________ Service Unit _______________
If your Juliette plans to earn this patch, we recommend you begin at the start of the Girl Scout year in October. Each year
your Juliette completes the requirements, they will be eligible to apply for an annual, color coded segment to accompany
the Golden Trefoil patch. Juliettes will be awarded Golden Trefoil patches at no cost if all criteria are met.
All of the following activities must be completed:
Juliette and caregiver must have a current Girl Scout membership
Juliette and caregiver must participate in Spring membership renewal
The Girl Scout program supports the three leadership keys incorporating girl planning, keeping in mind the
Safety Activity Checkpoints and Council Volunteer Policies and Procedures. Please have a discussion with your
Juliette about the top three skills they learned, tried, or gained in the past year. Then, have your Juliette give
examples of how she, as a Girl Scout, incorporated the following:
DISCOVER: ____________________________________________________________________________
TAKE ACTION: __________________________________________________________________________
Volunteer Participation - 2 out of the 4 activities must be completed:
Created a year plan for your Juliette* in VTK
Attended a volunteer training in person
Completed online volunteer training
80% of service unit volunteer meetings were attended by the Juliette caregiver
6 of the 11 activities listed below must be completed:
Participated in a membership recruitment event or Girl Scout visibility event (ie. Bring a Friend event, tabling 1.
event, wear your uniform day, etc.)
Date _______________ What we did ____________________________________________________
2. Attended at least one council-sponsored activity or Program Guide event
Date _______________ What we did ____________________________________________________
3. Attended at least one Service Unit-/Troop-hosted event
Date _______________ What we did ____________________________________________________
Participated in 4. both council-sponsored product programs
Fall Product Program sales: girl goal___________________________ Was it reached?______________
* If your Juliette is unable to participate in the fall product program, you do not need to complete this step of
the Golden Trefoil.
Girl Scout Cookie Program sales: girl goal ______________________ Was it reached?______________
Took part in a Take Action project or Service Project5.
At Girl Scout property __________________________________________________________________
At a non-Girl Scout location______________________________________________________________
Participated in activities within three of the four program pillars6.
Life Skills _____________________________________________________________________________
STEM ________________________________________________________________________________
Entrepreneurship ______________________________________________________________________
Participated in a Girl Scout Ceremony (7. investiture/rededication, court of awards, formal flag ceremony, etc.)
Date _______________ What we did ____________________________________________________
8. Participated in a discussion about Highest Awards
Date _______________ Girl interest? ____________________________________________________
9. Participated in a discussion about travel goals
Date _______________ Girl interest? ____________________________________________________
Check all that apply:
Participated in Day Trip
Participated in Overnight
Made a plan for Future Travel
10. The Juliette participated in a discussion/activity about the following three special Girl Scout days:
Juliette Gordon Low’s birthday/Founders Day (October 31)
What we did __________________________________________________________________________
World Thinking Day (February 22)
What we did __________________________________________________________________________
Girl Scout Week/birthday (March 12)
What we did __________________________________________________________________________
Decided what new Outdoor skill you would like to work on this year11.
Outdoor Skill __________________________________________________________________________
Golden Trefoil Application - Juliette
form #134b • 10/20 • page 2 of 3
Steps to receiving your Golden Trefoil patches:
1. By 6/30: Complete this form in its entirety. When it is completed, coordinate a time with your service unit Girl
Experience Mentor (GEM) to discuss your Juliette’s progress, and to approve your completed form. (Note: if your
service unit does not have a GEM, please reach out to your service unit manager to have the form approved.)
Service Unit GEM ________________________________________________
Approved? __________________________ Date ______________________
2. Due 8/31: Submit this form by emailing the completed form to A GSOSW staff
member will process your application, and send the patch via mail to the address listed above.
If you have questions, please contact Girl Scouts at 800-338-5248 or email
Golden Trefoil Application - Juliette
form #134b • 10/20 • page 3 of 3
Membership Year __________________ Service Unit # ___________ Grade Level ___________________________________
Name ___________________________________________________________ Phone ___________________________
Email _____________________________________________________________________________________________
________________________________________ City _______________________ State _____ ZIP _________
Please indicate in the chart below the number of patches you need.
Patches earned this year (free)
Replacement patches (1st year $2 each; segments $.75 each)
# Golden Trefoil patches # Golden Trefoil patches
# 1st year segments - purple # 1st year segments - purple
# 2nd year segments - blue # 2nd year segments - blue
# 3rd year segments - green # 3rd year segments - green
# 4th year segments - yellow # 4th year segments - yellow
# 5th year segments - orange # 5th year segments - orange
# 6th year segments - red # 6th year segments - red
Total # of free patches:
Total cost of replacement patches: