Girl Scout Council of the Mid-South

High Risk or Sensitive Issue Approval Request
Instructions:
  1. Fill out this form to begin a discussion with the council about your interest in offering a program activity that addresses a sensitive issue or an activity that is not listed as an activity checkpoint in Safety-Wise.
  2. Your field executive will respond within two weeks.
Fields marked with an asterisk * are required.
Troop/Group #:*
Leader/Advisor First Name:*
Leader/Advisor Last Name:*
Address:*
City:*
State:*
Zip:*
Girl Scout Membership Year:*
Service Unit:*
Age Level:* D Br Jr Teen Girl Scout 11-17
High Risk or Sensitive Issue Topic:*
Please give a brief description of the activity you are proposing:
Who has been involved in identifying this interest/need?
If you already have a facilitator/consultant in mind, please indicate who, their affiliation, and if and where you have observed them addressing this or a related topic.
Do you think you will have any girls or parents who might not be interested in participating in this activity? Yes No
If so, why not?
Request prepared by, First Name:*
Last Name:*
Position:*
Date:*
Best time to contact:*
Phone #:*
Email: 
Alternate Phone #: 

                             
You may submit form electronically by clicking submit or print and deliver to the
Girl Scout Council of the Mid-South
Mail: PO Box 240246, Memphis, TN 38124-0246
Deliver: 2715 Kirby Parkway, Suite 1
Fax: (901) 797-2183