GIRL SCOUTS OF THE PHILIPPINES

National Headquarters
Manila

CGSMS Form No. 1

CHIEF GIRL SCOUT MEDAL SCHEME

APPLICATION FORM
I. Personal Information
Name : __________________________________________________________________________________
Address : _________________________________________________________________________________
Telephone / CP No. : ______________________ _________________ Troop No. ________________ ____________
Region : NORTHERN LUZON Council : PANGASINAN
Troop Leader : __________________________________________________________________________________
Registration Dates : ___________________________________________________________________________________
Three (3) Years of Girl Scouting Experience : _ ______________________________________________________________
________________________________________________________________
________________________________________________________________

II. Badgework ( 2 Badges for each of the 8-Point Challenge )

Badges Earned Challenge Dates Earned

1 Well - Being
2 Well - Being
3 Arts
4 Arts
5 Preparedness
6 Preparedness
7 Family Life
8 Family Life
9 Environment
10 Environment
11 Economic Self - Sufficiency
12 Economic Self - Sufficiency
13 Heritage & Citizenship
14 Heritage & Citizenship
15 World Community
16 World Community

III. Camping Record:

Level Encampment Date Venue

Troop
District
Council
Regional
National
International

IV. Chief Girl Scout Medal Scheme Orientation / Workshop:

Date : October 17,2020 Place :

Submitted by : ___________________________ ______________

Name of Candidate

Noted by : ____ __________________________________

Troop Leader

EUFEMIA B. DE GUZMAN
Council Executive

LAILA F. MORALES
Attachments : Regional Executive Director
1. Troop Leader’s Endorsements
2. Parents’ Endorsements
3. Community Profile
Due Date : August 15

COMMUNITY PROFILE

1. Name of Purok / Zone _____________________ Population : ____________________

2. Barangay : ______________________________________________________________
Municipality /Province/City : _________________________________________________
3. No. of Families in the Purok : ________________ No. Interviewed : _________________
4. No. of Houses: ___________ Light material : ____________ Concrete :____________
5. No. of Houses with :Toilets : ________________ Electricity : _________________
Running Water : ___________ Deep Well : _________________
Flower Gardens : __________ Vegetable Gardens : ___________
Poultry : __________________ Piggery : ____________________
Others ( Specify ) _________________________________________
6. No. of School/s in the Purok / Zone : _________________________________________
7. No. of Church/Chapel in the Purok / Zone : ____________________________________
8. No. of Government offices located in the Purok / Zone : __________________________
9. No. of Hospital / Clinic in the Purok / Zone : ____________________________________
10. Community Centers available like Day Care, Reading, Health Center, others ( Specify ) in
the Purok / Zone __________________________________________________________
11. Means of transportation available in the Purok /Zone : ____________________________
_______________________________________________________________________
12. Recreational facilities are available : __________________________________________
________________________________________________________________________
13. Means of livelihood/occupations/employment of the people in the Purok/Zone__________
_______________________________________________________________________
14. Educational attainment of the : ( Indicate Number )
Men ( Elementary , High School ) : _____________________________________
Women ( Elementary , High School ) : _____________________________________
15. No. of School Children of School Age ( 6 Years – 21 Years )
In - School : _____________________ Out – of -School : ____________________
16. General conditions of : Roads : _____________ Drainage : _____________________
Park / Plaza : ______________ Playground : ________________
Market : _____________ Garbage Disposal : ________________
Trees & Other Plants : __________________________________
17. Person/s Interviewed : ____________________________________________________
____________________________________________________
____________________________________________________
18. Identified Three ( 3 ) Community Problem/Needs :
a. ________________________________
b. ________________________________
c. ________________________________

_________________________________
Chief Girl Scout Medal Candidate

_________________________________
Date
Noted By:

________________________________
Troop Leader
 Republic of the Philippines
MUNICIPALITY OF SANTA MARIA

Province of Pangasinan
Barangay San Alejandro

ENDORSEMENT

PANGASINAN GIRL SCOUT COUNCIL

Lingayen, Pangasinan

Madam:

As stipulated in the main objective of the Chief Girl Scout Medal Scheme in
which our daughter, ROSEMARIE CESARIO TABAYOYONG, an active Cadet
Girl Scout of Sta. Maria East Integrated School under Troop No. 1253 is qualified for
the Chief Girl Scout Medal Scheme. I, the mother of Rosemarie Cesario Tabayoyong is
willing to do my best to help my daughter in her developmental project entitled
“ECOLOGY: WASTE MANAGEMENT”.

Rest assured for my continued moral support.

VILMA C. TABAYOYONG
Mother
 Republic of the Philippines
MUNICIPALITY OF SANTA MARIA

Province of Pangasinan
Barangay San Alejandro

ENDORSEMENT
Pangasinan Girl Scout Council
Lingayen, Pangasinan

Madam:

Greetings!

After undergone consultation, orientation and reviewed of CHIEF GIRL

SCOUT MEDAL SCHEME PROGRAM, I hereby attest the veracity that
ROSEMARIE C. TABAYOYONG an active Cadet Girl Scout of Sta. Maria East
Integrated School under Troop No. 1253 is officially allowed and endorse her with
our best continued moral support to join and fullfill her environmental project
entitled: “Ecology: Waste Management” for the School Year 2020-2021.

Rest assured for our enormous support!

Respectfully yours,
 ENDORSEMENT

PANGASINAN GIRL SCOUT COUNCIL

Lingayen, Pangasinan

Madam:

This is to certify that ROSEMARIE CESARIO TABAYOYONG an active

Cadet Girl Scout of Sta. Maria East Integrated School under Troop No. 1253 is
qualified for the Chief Girl Scout Medal Scheme.

She is working on her project entitled “ECOLOGY: WASTE

MANAGEMENT”.

Therefore, I strongly recommend her for the Chief Girl Scout Medal Scheme for
the School Year 2020 - 2021.

JULIA A. PICO
Troop Leader
 ENDORSEMENT
Pangasinan Girl Scout Council
Lingayen, Pangasinan

Madam:

Greetings!

Through the power vested in me as Principal IV, I am endorsing

ROSEMARIE C. TABAYOYONG, an active Girl Scout of the Philippines at Sta.
Maria East Integrated School, Sta. Maria, Pangasinan to participate in the CHIEF
GIRL SCOUT MEDAL SCHEME (CGSMS) PROJECT, specifically on ECOLOGY:
“Waste Management” at Barangay San Alejandro, Sta. Maria, Pangasinan.
Rest assured for our enormous support!

Respectfully yours,

EMILY N. HIDALGO
Principal IV
 GIRL SCOUTS OF THE PHILIPPINES
Northern Luzon Region
Pangasinan Council

ENDORSEMENT

TO WHOM IT MAY CONCERN:

This is to certify that ROSEMARIE C. TABAYOYONG, Cadet Girl Scout of

Sta. Maria East Integrated School, Sta. Maria, Pangasinan has met all the requirements
for the Chief Girl Scout Medal Scheme for School Year 2020 – 2021 who had work on a
community project on ECOLOGY: “Waste Management”.
          We, therefore, strongly recommend her as National Awardee and one of the Chief
Girl Scout Medalists of the Pangasinan Girl Scout Council.

Noted By:

                                                                         EUFEMIA B. DE GUZMAN

Council Executive

     JUDY DL. VARGAS

               Council President