Section 1 of 9
Public Education & Citizenship Committee: Certificate Request Form
Lodges should use this form to request certificates from the Grand Lodge for Public Education & Citizenship Committee program initiatives. A separate form must be submitted for each certificate requested.
Please allow up to 30 days for processing.
Information on available certificates is provided in the Committee Program Book: [Insert Link Here].
Type of Certificate
Type of Certificate
Question Type
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Date
Time
1.
Adopt-A-School
2.
Adopt-A-Teacher
3.
Outstanding JROTC Cadet
4.
Certificate of Appreciation (First Responder/Community Leader/Educator/etc.)
5.
Girl Scout Gold
6.
Girl Scout Silver
7.
Outstanding Young Marines, Sea Cadets, Civil Air Patrol, JMCA Cadet
8.
Why I Love America Essay Contest Winner
9.
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Answer key
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Section 2 of 9
General Information
Lodge Name & Number
Lodge Name & Number
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Date
Time
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Presented By (Lodge Name, Worshipful Master, etc.)
Presented By (Lodge Name, Worshipful Master, etc.)
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Presenter Type
Presenter Type
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Date
Time
Lodge
Worshipful Master
Individual Brother
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Presented To (Award Recipient)
Presented To (Award Recipient)
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Mailing Address for Certificate
Mailing Address for Certificate
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Section 3 of 9
Adopt-A-School
Answer questions below only if submitting a request for an Adopt-A-School certificate.
Grade Level
Grade Level
Question Type
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Date
Time
Elementary
Middle (6-8)
High (9-12)
Senior High (11-12)
K-8
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Description of Activity
Description of Activity
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Date
Time
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Section 4 of 9
Adopt-A-Teacher
Answer questions below only if submitting a request for an Adopt-A-Teacher certificate.
School Name
School Name
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Date
Time
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School Address
School Address
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Grade Level / Courses Taught
Grade Level / Courses Taught
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Date
Time
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Section 5 of 9
Outstanding JROTC Cadet
Answer questions below only if submitting a request for an Outstanding JROTC Cadet certificate.
Branch
Branch
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Date
Time
Army
Navy
Marines
Air Force
Coast Guard
Space Force
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add "Other"
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Cadet's Rank & Assignment
Cadet's Rank & Assignment
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Date
Time
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Cadet's High School Name
Cadet's High School Name
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Paragraph
Multiple choice
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Date
Time
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Cadet's High School Address
Cadet's High School Address
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Short answer
Paragraph
Multiple choice
Checkboxes
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Date
Time
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Recommending Senior Military Instructor Name
Recommending Senior Military Instructor Name
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Multiple choice
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Date
Time
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Recommending Senior Military Instructor Rank
Recommending Senior Military Instructor Rank
Question Type
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Paragraph
Multiple choice
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Date
Time
Answer key
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Section 6 of 9
Certificate of Appreciation
Answer questions below only if submitting a request for a Certificate of Appreciation certificate.
Type of Certificate
Type of Certificate
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
First Responder
Educator
Community Leader
Other:
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Answer key
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Section 7 of 9
Scouting
Answer questions below only if submitting a request for an Eagle Scout, Girl Scout Gold, or Gold Scout Silver certificate.
Troop Name / Number
Troop Name / Number
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
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Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
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Section 8 of 9
Outstanding Youth Military Organization Cadet
Answer questions below only if submitting a request for an Outstanding Youth Military Organization Cadet certificate.
Cadet Branch
Cadet Branch
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
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Multiple choice grid
Checkbox grid
Date
Time
Young Marines
Sea Cadets
Civil Air Patrol
Joint Military Cadets of America
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or
add "Other"
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Answer key
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Cadet Name / Rank
Cadet Name / Rank
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
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Multiple choice grid
Checkbox grid
Date
Time
Answer key
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Section 9 of 9
"Why I Love America" Essay Contest Recipient
Answer questions below only if submitting a request for a "Why I Love America" Essay Contest recipient certificate.
Recipient's Grade
Recipient's Grade
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
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File upload
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Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
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Recipient's School Name
Recipient's School Name
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
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Recipient's School Address
Recipient's School Address
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
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