Fill - Free fillable 524-501 Adult Application | Boy Scouts Of America PDF form

ADULT APPLICATION

This application is also available in Spanish. Esta solicitud también está disponible en español.

02/2020

Youth Protection Training

All adult applicants are required to take

this training in order to complete the adult

application process. Go to my.Scouting.org

to create an account and take the

training online or contact your local council

for classroom training. Include a copy of your

completion certicate with this application.

Mission

The mission of the BSA is to prepare

young people to make ethical and

moral choices over their lifetimes

by instilling in them the values

of the Scout Oath and Scout Law.

Your participation in the BSA can help youth become better citizens.

Adult leaders serve as important role models for youth in the BSA and this application aids the chartered organization

in selecting qualied adult volunteer leaders.

Excerpt From the Declaration of Religious Principle

The BSA maintains that no member can grow into the best kind of citizen without recognizing an obligation to God and, therefore, recognizes

the religious element in the training of the member, but it is absolutely nonsectarian in its attitude toward that religious training. Its policy

is that the home and organization or group with which the member is connected shall give denite attention to religious life. Only persons

willing to subscribe to these precepts from the Declaration of Religious Principle and the Bylaws of the BSA shall be entitled to register.

Criminal Background Check*

In order to complete the adult application

process, you will need to review the

different disclosures that have been

separately provided to you. The separate

authorization form must be signed and

returned when you submit your application.

*The three different background check forms must be torn off and each separately given to the applicant.

SKU 655528

524-501 2020 Printing

Leader Requirements

The BSA is open to all who meet the requirements, and leaders are selected based on individual merit.

Adult leaders must possess the moral, educational, and emotional qualities that the BSA deems

necessary for positive leadership to youth. They must also:

• Abide by the Scout Oath, Scout Law, and Scouter Code of Conduct. The Scouter Code of Conduct can

be found at www.scouting.org/health-and-safety/gss/bsa-scouter-code-of-conduct/.

• Subscribe to the precepts of the Declaration of Religious Principle.

• Reside within the USA or a U.S. territory, or be a U.S. citizen residing outside the USA.

• Be 21 years of age or older for primary leadership positions.

• Be 18 years of age or older for assistant leadership positions.

• Complete Youth Protection training (YPT) before application is processed and renew training

as required by going to my.Scouting.org and creating an account.

• Review the disclosure information related to the BSA’s background check process and complete and

sign a Background Check Authorization form.

• Take leader position-specic training at my.Scouting.org. Classroom training may also be available

through your local council.

APPROVAL REQUIRED—UNIT ADULTS

Chartered organization head or chartered organization representative. The chartered organization

representative is approved by the head of the chartered organization. All other adult leader

applications must be accepted and approved by the head of the chartered organization or the

chartered organization representative.

APPROVAL REQUIRED—COUNCIL and DISTRICT ADULTS

Scout executive or designee must accept and approve all council and district adults.

Scout executive or designee must approve any adults who answer “yes” to any Additional

Information question.

The adult leader application process will not be complete until Youth Protection training has been

completed and a criminal background check has been obtained.

Health information. You should inform your unit leadership of any condition that might limit your

participation. Before participating in activities with your unit, please ll out the Annual Health and

Medical Record, No. 680-001, found on www.scouting.org/forms and provide it to your unit leadership.

Scouting magazine. All registered, paid adult leaders receive Scouting magazine; $2 of the registration

fee is for the subscription.

Boys’ Life. Registered adults get a special rate. For a subscription to a magazine that helps

children grow in the Scouting program, just ll in the Boys’ Life circle on the application and pay

the subscription price.

The annual national registration fee is nonrefundable.

BSA Privacy Policy

The BSA protects the condentiality of the names and personal information of those who are afliated

with the organization. No commercial or unauthorized use is made of the names, addresses, and other

condential information. The BSA and its afnity groups may use registration information to notify

registrants of benet opportunities.

For general questions, contact your local BSA council.

What Is the BSA Program?

The BSA program is outlined in the ofcial publications of the BSA. Activities that are not in these BSA

publications are not a part of the Scouting program. Leaders must not allow youth members or program

participants to engage in any unauthorized or prohibited activities.

Training for New Leaders

The BSA is committed to your success as a volunteer while serving young people. To help you be

successful there are training materials designed for you. Training resources are available through your

local council and at my.Scouting.org.

What Makes a Trained Leader?

You are considered a trained leader when you have completed leader position-specic training for

your position and have current Youth Protection training.

Youth Protection Begins With You™

Child abuse is a serious problem in our society, and unfortunately, it can occur anywhere, even in

Scouting. For that reason, the BSA continues to create barriers to abuse beyond what have previously

existed in Scouting.

The BSA is committed to providing a safe environment for young people. All adult leaders must complete

Youth Protection training as part of the registration process and renew their training as required. It is

highly recommended that parents who participate in Scouting activities complete YPT. To learn more

about the BSA’s Youth Protection resources, go to www.scouting.org/training/youth-protection/.

Mandatory Reporting

All persons involved in Scouting must immediately report to local authorities any good-faith suspicion

or belief that any child is or has been physically or sexually abused; physically or emotionally neglected;

exposed to any form of violence or threat; or exposed to any form of sexual exploitation including the

possession, manufacture, or distribution of child pornography, online solicitation, enticement, or showing

of obscene material. No person may abdicate this reporting responsibility to any other person.

Additionally, any known or suspected abuse or behavior that might put a youth at risk must also be

reported to the local Scout executive or the Scouts First Helpline (1-844-SCOUTS1 or 1-844-726-8871)

if your Scout executive or local council cannot be reached.

Youth Protection Policies

• Two registered adult leaders 21 years of age or over are required at all Scouting activities, including

meetings. There must be a registered female adult leader over 21 in every unit serving females.

A registered female adult leader over 21 must be present for any activity involving female youth.

• One-on-one contact between adult leaders and youth members is prohibited both inside and

outside of Scouting.

These and other key Youth Protection policies are addressed in the training and at www.scouting.org/

training/youth-protection/.

To learn about the BSA’s other health and safety policies, please review the online version of the Guide to

Safe Scouting, the Scouter Code of Conduct, and the Sweet Sixteen of BSA Safety, which are available at

www.scouting.org/health-and-safety.

Scout Oath

On my honor I will do my best to do my duty to God and my country and to obey the Scout Law; to help

other people at all times; to keep myself physically strong, mentally awake, and morally straight.

Scout Law

A Scout is trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean,

and reverent.

Signature of applicant Date

Email address Work

(Select one)

Home

Yes No

Boys’ Life

subscription

Country Home address City State Zip code

First name (Full legal name) Middle name Last name Sufx

/ /

Ethnic background: Driver’s license No. State Gender

Social Security No. (required) Occupation Employer

Primary phone Alternate phone Ext. Date of birth (mm/dd/yyyy)

- -

Country Business address City State Zip code

- - X

- -

/ /

Position code Scouting position title Are you an Eagle Scout? Date earned (mm/dd/yyyy)

Black/African American

Caucasian/White

Native American

Hispanic/Latino

Alaska Native

Pacic Islander

Asian

Other

Preferred nickname:

○

○ ○

○

○ ○

524-501

○

YPT completion certicate attached Background Check Authorization form attached

○

To be completed by unit

Careful review of the information provided on this application is a significant step in Scouting’s efforts to protect its youth members and deliver a quality program.

Unit

No.

○

New leader

○

Former leader

○

Position change

○

Participant

Unit

type:

○

Pack

○

Troop

Crew

○

Transfer application

Enter membership number

from unexpired certicate:

Council No.:

Unit No. or

District name:

○

Ship

District name

Unit

type:

○

Pack

○

Troop

Crew

○

Ship

○

○ ○

○

Multiple application

Registration

fee

Boys’ Life

fee

PAID: ○ Cash ○ Check No. ________ ○ Credit card

○

M F

Please print one letter in each space.

Signature of chartered organization head or representative Date Signature of Scout executive or designee Date

APPROVALS FOR UNIT ADULTS: I have reviewed this application and the responses to any questions answered “Yes,” and

have made any follow-up inquiries necessary to be satised that the applicant possesses the moral, educational, and

emotional qualities to be an adult leader in the BSA.

APPROVAL FOR COUNCIL AND DISTRICT ADULTS: I have reviewed this application and have made any follow-up inquiries

necessary to be satised that the applicant possesses the moral, educational, and emotional qualities to be an adult leader

in the BSA.

BSA ADULT APPLICATION

I hereby certify that:

1. I have read and afrm that I accept the Declaration of Religious Principle. I agree to comply with the rules and regulations of

the BSA and the local council, including the Scouter Code of Conduct.

INITIALS

REQUIRED

_________

2. I afrm that the information contained in this application is true and accurate to the best of my knowledge and belief. INITIALS

REQUIRED

_________

All questions MUST be answered. Write NONE if applicable.

1. Scouting background.

Position Council Year

____________________________________

2. Experience working with youth in other

organizations. Please provide contact information.

____________________________________

3. Previous residences (for last 10 years).

City State

_______________________ ____________

4. Current memberships (religious, community,

business, labor, or professional organizations).

____________________________________

5. References. Please list those who are familiar with

your character. References may be checked.

Name __________________________________

Telephone (_____) _________________________

Name __________________________________

Telephone (_____) _________________________

Name __________________________________

Telephone (_____) _________________________

6. Additional information. Yes No

(Mark each answer.)

a. Have you ever been removed from

or asked to leave a leadership

position in an organization due to

allegations regarding your personal

conduct or behavior? Explain:

____________________________________

b. Do you use illegal drugs or abuse

alcohol? Explain:

____________________________________

c. Have you ever been arrested for a

criminal offense (other than minor

trafc violations)? Explain:

____________________________________

d. Has your driver’s license ever been

suspended or revoked? Explain:

____________________________________

e. Have you ever been investigated for,

accused of, or charged with abuse or

neglect of a minor child? Explain:

____________________________________

f. Are you aware of any reason

not listed above that may call

into question your suitability to

supervise, guide, care for, and lead

young people?

____________________________________

If applicant has an unexpired membership certicate, registration may be accomplished at no charge by transferring the registration

or multiple registering.

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

BACKGROUND CHECK

DISCLOSURE

A consumer report is a background check in which information (which may include, but is not limited to,

criminal background, driving background, character, general reputation, personal characteristics, and mode of

living) about you is gathered and communicated by a consumer reporting agency (“CRA”) to Boy Scouts of

America and/or its subsidiaries, affiliates, other related entities, and/or successors (the “Company”).

Company may obtain a consumer report on you to be used for employment purposes (in your case, this means

for the purpose of evaluating you as a new or existing volunteer).

Tear off the following pages and provide to applicant separately.

CALIFORNIA

STATE LAW DISCLOSURES

(Non-Credit)

Under California law, an “investigative consumer report” is a consumer report in which information on a

consumer’s character, general reputation, personal characteristics, or mode of living is obtained through any

means. Boy Scouts of America and/or its subsidiaries, affiliates, other related entities, and/or successors (the

“Company”) may obtain an investigative consumer report (which may include information described above)

from an investigative consumer reporting agency (“ICRA”) on you in connection with your status as a

volunteer (i.e., for employment purposes under California law). The nature and scope of this investigation

includes your character, general reputation, personal characteristics, or mode of living information, including

criminal history and driving record.

The ICRA preparing the investigative consumer report and conducting the investigation will be First

Advantage, P.O. Box 105292, Atlanta, GA 30348, 800-845-6004. Information regarding First

Advantage’s privacy practices can be found at https://fadv.com/privacy-policy/.

Under California Civil Code section 1786.22, you are entitled to a visual inspection of files maintained on

you by an ICRA, as follows:

(1) In person, if you appear in person and furnish proper identification, during normal business hours and

on reasonable notice. A copy of your file shall also be available to you for a fee not to exceed the

actual costs of duplication services provided;

(2) By certified mail, if you make a written request, with proper identification, for copies to be sent to a

specified addressee. An ICRA complying with requests for certified mailings under California Civil

Code section 1786.22 shall not be liable for disclosures to third parties caused by mishandling of mail

after such mailings leave the ICRA;

(3) A summary of all information contained in your files and required to be provided by California Civil

Code section 1786.10 shall be provided to you by telephone, if you have made a written request, with

proper identification for telephone disclosure, and the toll charges, if any, for the telephone call are

prepaid by you or charged directly to you.

“Proper Identification,” as used above, means information generally deemed sufficient to identify you, which

includes documents such as a valid driver’s license, social security account number, military identification card,

and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional

information concerning your employment and personal or family history in order to verify your identity.

The ICRA will provide trained personnel to explain any information furnished to you pursuant to California

Civil Code section 1786.10 and will provide a written explanation of any coded information contained in files

maintained on you. This written explanation will be provided whenever a file is provided to you for visual

inspection under California Civil Code section 1786.22.

You may be accompanied by one other person of your choosing, who must furnish reasonable identification.

An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file

in such person’s presence.

40832775.1

ADDITIONAL DISCLOSURES & BACKGROUND CHECK AUTHORIZATION

Additional Disclosures

The state disclosures below are included because state law requires them to be provided in

writing. Some of the below rights, notices, or information also may apply to individuals from,

applying to, or volunteering in states not listed below. There may be additional requirements,

options, or provisions applicable to you and you may have additional rights under

applicable law that are not required to be disclosed to you in writing.

Minnesota: You have the right to request a complete and accurate disclosure of the nature and scope

of any consumer report from First Advantage, P.O. Box 105292, Atlanta, GA 30348, 800-845-6004.

New York: Boy Scouts of America and/or its subsidiaries, affiliates, other related entities, and/or

successors (the “Company”) may request or utilize subsequent consumer reports (other than

investigative consumer reports) on you throughout your volunteer relationship with Company. Upon

request, you will be informed whether or not a consumer report was requested, and if such report was

requested, informed of the name and address of the CRA that furnished the report. Your written

request should be made to Company at Boy Scouts of America, Membership Standards Team S201,

1325 West Walnut Hill Lane, P.O. Box 152079, Irving Texas 75015-2079. You may also contact the

Company by email at MembershipStandards@scouting.org

AUTHORIZATION

(Please print)

Name: First ____________________ Middle _______________

Last ________________________ Suffix _________

List any other names used (nickname, maiden/married last names: _________________________________________

Date of Birth: _______________________________

Unit Type and Number: _______________________________

To the extent permitted by applicable law, I hereby consent to and authorize the Boy Scouts of

America and/or its subsidiaries, affiliates, other related entities, and/or successors (the “Company”)

to procure consumer report(s) (as defined by federal law) and/or investigative consumer report(s) (as

defined by applicable California state law), which in my case means criminal background

check(s)/driving record(s), on my background from a consumer reporting agency (“CRA”) or from an

investigative consumer reporting agency (“ICRA”), as described in the Background Check

Disclosure and the California State Law Disclosures (Non-Credit) (each of which I have

received separately from the Company), as well as these Additional Disclosures & Background

Check Authorization. This authorization applies only to criminal checks/driving records and does

not allow the Company to obtain credit checks. I have reviewed and understand the information,

statements, and notices in the Background Check Disclosure and the California State Law

Disclosures (Non-Credit), as well as these Additional Disclosures & Background Check

Authorization. My authorization remains valid throughout my volunteer relationship with the

Company, such that, to the extent permitted by applicable law, I agree Company can procure

additional consumer report(s), which in my case means criminal background check(s)/driving

record(s), during my volunteer relationship without providing additional disclosures or obtaining

additional authorizations. Except as otherwise prohibited by applicable law, I consent to and

authorize the Company to share this information with Company’s local councils and/or chartered

organizations for business reasons (e.g., to place me in certain positions, work sites, etc.). I

understand that, if I am selected for a volunteer position, a consumer report will have been

conducted on me.

For California, Minnesota, or Oklahoma individuals: If you would like to receive from the

CRA, the ICRA, or the Company (as applicable) a copy of the report that Company may procure, please

check this box.

Signature _______________________________________ Date ________________________________________