Girl Scouts of Western Rivers Council * Summer Lovin' Fun Patch Program

Date __________

Leader's Name _____________________________

Troop/Group #________Program Level_________

Mailing Address_________________________City_______________

State___________    Zip__________

Phone #______________

Number of 1st year patches _____ X $2.00 = $__________
Number of 2nd year patches_____ X $ .80 = $__________
Number of 3rd year patches_____ X $ .80 = $__________
Number of 4th year patches_____ X $ .80 = $__________
Number of 5th year patches_____ X $ .80 = $__________
Number of 6th year patches_____ X $ .80 = $__________
Number of 7th year patches_____ X $ .80 = $__________

8th year and above call the Eugene service center for information

Postage and Handling (only if ordering by mail)