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* 1. Troop Leader/Guardian Name

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* 2. Troop Leader/Guardian Phone Number or Email Address

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* 3. Troop Number

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* 4. Town

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* 5. Program Level

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* 6. Name of badge completed

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* 7. How many girls in your group completed this badge?

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* 8. Respond to the following facts with the statement that most describes you.

  Definitely Kind Of Not Really No
1) I know what foods to eat to give me energy.
2) I know how the food I eat impacts my body.
3) I can make good decisions around what food to eat.
4) I know how much exercise I need each week.
5) I can help my family make healthy eating choices.
6) I know someone I can talk with to find out more about being healthy.
7) I want to work toward having healthier food at my school.
8) I feel comfortable sharing what I know about healthy living with others.
9) I am comfortable speaking up to ask for healthy food choices.
10) I understand that exercise makes me feel better.
11) I know what kinds of food are healthy for me.

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* 9. When you have answered all of the questions, print a copy of this survey before you click "Done." Bring that printout to your nearest GSCWM Service Center to get your award for free, thanks to a generous grant from Fallon Community Health Plan.

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* 10. For ideas on how to connect these badges to your Girl Scout Journey, check out the "Healthy Habits" booklets, which explore fun, easy ways to achieve energy balance. Download them today at www.girlscouts.org/program/journeys/booklets

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