MEDIA CORPS
All Levels of Girl Scouts are needed to serve
as members of the MEDIA CORPS. GSSJC
MEDIA CORPS is composed of girls who are
called upon to respond to public relations,
marketing and media opportunities for the
Council.
REQUIREMENTS:
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You must provide your own
transportation;
Fill out this form completely;
Provide a non-returnable photograph
with this form. That’s it!
PLEASE ATTACH
YOUR PHOTO HERE
(School photos are greatbut any photo will do.)
Some of the things you may be called upon to do are…
Appear on TV talk show ● Pose for publicity photos ● Be interviewed by a newspaper or
television reporter ● Participate in televised promotional events ● March in parades ●
Conduct flag ceremonies ● Star in Girl Scout TV commercials ● Perform in Council training
and promotional videos! Being a MEDIA CORPS member is a lot of fun!
If this sounds like something you would be interests in doing, fill out the information below,
have your parents sign the publicity release on the back of this form, and mail the form and a
current photograph to: GSSJC, Communications, 3110 Southwest Freeway, Houston, TX
77098. Call 713-292-0361 for more information.
Today’s Date ____________ Date of Birth ____________ Do you speak another language fluently? If so,
please list language. _____________
Name ______________________________________ Preferred Phone Number _____________________
Email address __________________________________________________________________________
Address ______________________________________ City _____________________ Zip ___________
Girl Scout level _________________ Community/Region (if known) _________________________
School _____________________________ School District ______________________ Grade level ______
Parents’/Guardians’ Names
_______________________________________________________________________
Parent/Guardian Email Address___________________________________________________________
Parent/Guardian phone (day) __________________________ Person at this number
________________________
If the day is a work number, can you receive calls at work? ______ Phone (night) _____________________
If you are in a troop or participate in a special interest group, please list troop # or group: _____________
Girl Scout Adult/Leader ________________________________ Girl Scout Adult/Leader’s phone
_________________________
Do you have access to a complete Girl Scout uniform? □ YES □ NO
Not all events require a complete uniform.
Girls in grades 9-12 − Would you be interested in being a part of a Girls Speakers Bureau and presenting your
personal success stories at various events? □ YES □ NO
Girl Scouts of San Jacinto Council
PUBLICITY RELEASE
I, _____________________________, hereby give Girl Scouts of San Jacinto Council, its successors
Girl’s Name (Please Print)
and assigns and those acting under its permission or upon its authority, the unqualified right and
permission to reproduce, copyright, publish, circulate, or otherwise use photographic reproductions or
likenesses of me and/or my name. This authorization and release covers the use of said materials in any
published form, electronic media, and medium of advertising, publicity, or trade in any part of the world
for an unlimited period of time.
___________________________________________________
Signature of Girl
___________________________________________________
Date
___________________________________________________
Signature of parent or guardian
___________________________________________________
Date
___________________________________________________
Telephone
GSSJC F-70
05/13