GSSJC Adult Pin and Rocker Form

GSSJC Adult Pin and Rocker Form
O-57, F-56 and F-61 - ALL IN ONE!

This form replaces O-57 Continuing Leader rocker order, F-56 Years of Membership and the F-61 Years of Service forms. Please read through and answer each section for your community or committee.
Before you get started...

There are four main sections of this form:
1. Community or Committee Information
2. Pins to be awarded at Council Recognition Event
3. Years of Membership pins to be awarded at Community or committee recognition event.
4. Years of Service pins to be awarded at Community committee recognition event.
You will not need to complete all sections if they do not apply to your order. The questions will guide you to skip through as needed.

You may find it helpful to have the following ready before you begin:
- Names of all members receiving pins and for what years
- If requesting adults be recognized at Adult Recognition Event for 20+ years of membership or service, an F-122 Volunteer Service Record is required for each adult being recognized. You will write a short biography for each person requesting to receive a year pin at Adult Recognition Event, then upload the F-122. Please be certain that the adults requesting service or membership recognition at the council recognition event are registered for or planning to attend prior to completing this request.
- Date of your community or committee recognition event (orders must be placed no less than 4 weeks prior, and will not be available for pickup until after March 15.)
- Number of returning leaders who need Continuing Leader rockers for the current year.
You WILL receive an option at the end of the form to review/save your answers. Please keep a copy of this and forward it to your staff or volunteer partner to prevent order duplication.

Community/Committee Recognition Pin Order Information

Please give us some information about your group and how you would like to receive this pin order.
Group Name*
Community*
Date of your Community or Committee Recognition event*

MonthDayYear
This could be your final summit meeting of the year, a special volunteer/leader dinner or other event like a Bridging Ceremony. Orders placed less than 4 weeks prior to a recognition event are not guaranteed. Orders will not be available until after March 15.
Number of Administrative roles that serve this group*
Administrative roles include Community Service Team, Region Service Team and council-wide committee roles. Groups without official administrative volunteers may enter "0."
Number of Troop Leaders who will receive "25-26" Continuing Leader rocker patches this year in your community.*
Orders for previous years may be submitted to adultrecognition@sjgs.org. "Fearless Leader" patch may be purchased in the Girl Scout Shop. Committees without troop leaders may enter "0."
Your Name*

First NameLast Name
Your ROLE in the community or committee*
Ex: Community Recognitions Chair
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How would you like to receive your Order? (All orders for community or committee events must be placed 4-6 weeks prior to event date and no later than 5 business days before pickup. Orders will not be available until after March 15. )*

Volunteer Experience Manager or Staff Partner will pick upA volunteer will pick upMail them (Community pays postage)
Date of Order Pickup*

MonthDayYear
Please allow at least five business days for orders to be fulfilled. Some orders may require additional pins to be ordered from the national shop. If a delay is expected, you will be notified.
Name of Volunteer or staff member picking up your order*

First NameLast Name
From which GSSJC Resource Center would you like to pick up?*
Please enter name and full mailing address of team member receiving order on behalf of your community.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Years of MEMBERSHIP Pins to be awarded at Community (local) or committee event.
Our group DOES have Years of MEMBERSHIP to be awarded in our area.*

YesNo
Please list your adult members' First and Last name, separated by commas, under the appropriate pins. These pins will NOT be awarded at the council's adult recognition event. All members receiving awards must be current members in good standing. Girl membership numeral guards for 5- and 10-year membership may be purchased at the Girl Scout Shop.
5 Years of MEMBERSHIP
10 Years of MEMBERSHIP
15 Years of MEMBERSHIP
20 Years of MEMBERSHIP
25 Years of MEMBERSHIP
30 Years of MEMBERSHIP
35 Years of MEMBERSHIP
ALL other years of MEMBERSHIP - These must be in increments of FIVE (5)

Years of SERVICE Pins to be awarded at Community (local) or committee event.
Our group DOES have Years of SERVICE to be awarded in our area.*

YesNo
Please list your volunteers' First and Last names under the appropriate pins. The years of service pin are Volunteer years an adult has served Girl Scouts in any/all councils to which they have belonged. These pins will NOT be awarded at the council's adult recognition event. All members receiving awards must be current members in good standing. Volunteers receiving years of service pins must have a current background check on file.
5 years of SERVICE
10 years of SERVICE
15 years of SERVICE
20 years of SERVICE
25 years of SERVICE
ALL other years of SERVICE- These must be in increments of FIVE (5)
Your Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature

Clear
Should be Empty:

	N/A	20	25	30	35	40	50
Years of Membership
Years of Service

	N/A	20	25	30	35	40	50
Years of Membership
Years of Service

	N/A	20	25	30	35	40	50
Years of Membership
Years of Service

	N/A	20	25	30	35	40	50
Years of Membership
Years of Service

GSSJC Adult Pin and Rocker Form

Community/Committee Recognition Pin Order Information

Pins to be Awarded at the council's Adult Recognition Event on April 18, 2026.

Years of MEMBERSHIP Pins to be awarded at Community (local) or committee event.

Years of SERVICE Pins to be awarded at Community (local) or committee event.