Fill - ADuLt APPLicAtioN Boy ScoutS of AmericA

Boy ScoutS of AmericA

ADuLt APPLicAtioN

In a Cub Scout pack, Boy Scout troop, Varsity Scout team, Venturing crew, or Sea Scout ship—or in any position in a district or

council—your participation is a service to your community and helps youth become better citizens.

Quality leadership is important in the training of youth as members of the Boy Scouts of America. This application helps select the

best individuals for their volunteer roles. Thank you for completing all items in this application. See instructions on the inside cover.

524-501A 909

Youth Protection Training

All volunteers are expected to complete Youth

Protection training. It is available online on the

Web site www.scouting.org and each local council

provides training to leaders on a regular basis

throughout the year. As a volunteer, you are

expected to complete the training within 90 days

of assuming a leadership position.

For more information, refer to the back of the

applicant copy.

BY SUBMITTING THIS APPLICATION YOU ARE AUTHORIZING

A CRIMINAL BACKGROUND CHECK OF YOURSELF.

THIS CHECK WILL BE MADE FROM PUBLIC RECORD SOURCES.

YOU WILL HAVE AN OPPORTUNITY TO

REVIEW AND CHALLENGE ANY ADVERSE

INFORMATION DISCLOSED BY THE CHECK.

IF YOU WOULD LIKE A COPY OF YOUR CRIMINAL BACKGROUND

REPORT, PLEASE CONTACT YOUR LOCAL COUNCIL OFFICE.

The mission of the Boy Scouts

of America 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 Law.

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Tips for completing the Application for Adult Membership:

(Use blue or black ink)

➢ Print—do not use cursive.

➢ Use black or dark blue ink.

➢ Press ﬁrmly when printing.

➢ Print one letter only in each box.

➢ Use upper-case letters and stay within the blue boxes for legibility.

➢ Fill in circles; do not use check marks.

➢ Make sure you have all needed signatures on application.

➢ Don’t alter the application—it could affect the quality of the scan.

Mailing address example:

7 0 3 F I R S T S T

Purpose of the Boy Scouts of America

The purpose of the Boy Scouts of America is to promote, through cooperation with other agencies,

the ability of youth to do things for themselves and others, and to teach youth patriotism, courage,

self-reliance, and kindred virtues. In achieving this purpose, emphasis is placed upon the Boy Scouts

of America’s educational program and its oaths, promises, and codes for character development,

citizenship training, and mental and physical ﬁtness.

Excerpt From Declaration of Religious Principle

The Boy Scouts of America 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 deﬁnite attention

to religious life. Only persons willing to subscribe to these precepts from the Declaration of Religious

Principle and to the Bylaws of the Boy Scouts of America shall be entitled to certiﬁcates of leadership.

Leadership Requirements

The applicant must possess the moral, educational, and emotional qualities that the Boy Scouts of

America deems necessary to afford positive leadership to youth. The applicant must also be the correct

age, subscribe to the precepts of the Declaration of Religious Principle, and abide by the Scout Oath or

Promise, and the Scout Law.

APPROVAL REQUIRED—UNIT SCOUTERS

Unit committee chairman approves all adult personnel except the chartered organization representa-

tive and committee chairman.

Chartered organization head or chartered organization representative. The chartered organization

representative is approved by the head of the chartered organization. Following approval by the unit

committee chairman, all other adult unit personnel must be approved by the head of the chartered

organization or the chartered organization representative.

Scout executive or designee must approve all unit Scouters.

APPROVAL REQUIRED—COUNCIL and DISTRICT SCOUTERS

Scout executive or designee must approve all council and district Scouters.

Scouting magazine. This magazine is sent to all registered, paid adult members.

Boys’ Life. Registered adults get a special rate of $12 a year (half the regular rate of $24 a year). For a subscription to a great

magazine and up-to-date information on boys and Scouting, just attach the appropriate amount and ﬁll in the Boys’ Life circle.

Please calculate and remit the appropriate state and local taxes. On late registrations it may be necessary to deliver back issues.

Qualiﬁcation. Adult citizens, or adult noncitizens who reside within the country, may register with the Boy Scouts of America in

any capacity if they agree to abide by the Scout Oath or Promise and the Scout Law, to respect and obey the laws of the United

States of America, and to subscribe to the precepts of the Declaration of Religious Principle. All leaders must be 21 years of age

or older, except assistant Scoutmasters, assistant den leaders, assistant Cubmasters, assistant Webelos den leaders, and assis-

tant Varsity Scout coaches, who must be 18 or older. No one may register in more than one position in the same unit, except the

chartered organization representative (who can multiple only as the committee chairman (CC) or a committee member (MC))

and the ScoutParent unit coordinator (who may multiple as chartered organization representative (CR), assistant den leader (DA),

assistant Webelos den leader (WA), assistant Scoutmaster (SA), assistant Varsity Scout Coach (VA), mate (MT), and Leader of

11-year-old Scouts (10)).

I submit my $15 registration fee for one year, $2 of which is to cover a subscription to Scouting magazine. Short-term fees are

pro rata amounts as indicated.

Ethnic Background Information. The BSA receives inquiries from various agencies regarding racial composition. Please ﬁll in

the appropriate circle on the application to indicate ethnic background.

BSA Privacy Policy. The Boy Scouts of America protects the conﬁdentiality of the names and personal information of those who

are afﬁliated with the movement. No commercial or unauthorized use is made of the names, addresses, and other conﬁdential

information of members. Access to this information is strictly limited.

This application is designed to be an information-gathering aid. Answers given by the applicant are to be veriﬁed in

those instances where a legitimate question arises as to his/her qualiﬁcations.

INSTRUCTIONS

Unit Scouters

1. Complete and sign the top copy. Keep the back copy (applicant copy) and give the remaining copies to the committee

chairman with the proper fees.

2. After the application has been reviewed and, if necessary, references checked by the unit committee, secure the approvals.

The process set forth in the publication Selecting Quality Leaders, No. 18-981, must be completed for all positions of

Scoutmaster, assistant Scoutmaster, Varsity Coach, and assistant Varsity Coach.

3. The committee chairman keeps the unit copy, gives one copy to the chartered organization, and forwards the remaining

copy to the local council service center for approval and processing.

Council and District Scouters

1. Complete and sign the application.

2. Send the proper fee and all three copies of the application to the local council service center for approval and processing.

FEE CHART

Months Registration Boys’

Life

1 1.25 —

2 2.50 2.00

3 3.75 3.00

4 5.00 4.00

5 6.25 5.00

6 7.50 6.00

7 8.75 7.00

8 10.00 8.00

9 11.25 9.00

10 12.50 10.00

11 13.75 11.00

12 15.00 12.00

UNIT POSITION CODE

CR Chartered organization representative

CC Committee chairman

MC Committee member

SM Scoutmaster **

SA Assistant Scoutmaster**

NL Crew Advisor

NA Crew associate Advisor

SK Skipper

MT Mate

VC Varsity Scout Coach**

VA Assistant Varsity Scout Coach**

CM Cubmaster**

CA Assistant Cubmaster**

WL Webelos den leader**

WA Assistant Webelos den leader**

DL Den leader **

DA Assistant den leader**

TL Tiger Cub den leader

PT Pack trainer

PC ScoutParent unit coordinator

10 Leader of 11-year old Scouts (LDS Troop)

88 Lone Cub Scout friend and counselor**

96 Lone Scout friend and counselor**

ScoutParents (PS) and Tiger Cub adult partners (AP)

complete the bottom portion of the youth application.

**Will receive Program Helps as inserts in Scouting.

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Instructions:

Please read the Authorization and Disclosure Statement on the back of this page. In the space provided

at the bottom of the statement, ﬁll in the spaces for your name, signature and date to acknowledge your

review of the form.

This Authorization and Disclosure Statement and the Boy Scouts of America Adult Application must

be signed and turned in together to complete the application process.

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NOTICE TO APPLICANT REGARDING BACKGROUND CHECK

In order to safeguard the youth in our care, the Boy Scouts of America will procure consumer reports

on you in connection with your application to serve as a volunteer, and the Boy Scouts of America

may procure additional consumer reports at any time during your service as a volunteer in order to

evaluate your continued suitability for volunteer service. The Boy Scouts of America has contracted

with LexisNexis, a consumer reporting agency, to provide the consumer reports. LexisNexis may

be contacted by mail at LexisNexis, 1000 Alderman Drive, Alpharetta, GA 30005 or by telephone at

800-845-6004.

The consumer reports may contain information bearing on your character, general reputation,

personal characteristics, and mode of living. The types of information that may be obtained include

but are not limited to Social Security number veriﬁcation, sex offender registry checks, criminal

records checks, inmate records searches, and court records checks. The information contained

in these consumer reports may be obtained by LexisNexis from public record sources.

The consumer reports will not include credit record checks or motor vehicle record checks.

The nature and scope of the consumer reports are described above. Nonetheless, you are

entitled to request a complete and accurate disclosure of the nature and scope of such reports

by submitting a written request to LexisNexis at the address listed above. Additional notices

for applicants in California, New York, Minnesota, and Oklahoma are provided.

APPLICANT’S ACKNOWLEDGMENT AND AUTHORIZATION

I have carefully read this notice and authorization form and I hereby authorize the Boy Scouts of

America and LexisNexis to procure a consumer report, which as described above will include

information relating to my criminal history as received from reporting agencies. I understand that

this information will be used to determine my eligibility for a volunteer position with the Boy Scouts

of America. I also understand that as long as I remain a volunteer, additional consumer reports may

be procured at any time. I understand that if the Boy Scouts of America chooses not to accept my

application or to revoke my membership based on information contained in a consumer report, I will

receive a summary of my rights under the Fair Credit Reporting Act and contact information for the

reporting agency, LexisNexis.

ADDITIONAL NOTICES TO CALIFORNIA, MINNESOTA, OKLAHOMA,

AND NEW YORK APPLICANTS

California

Under California law, the consumer reports described above that the Boy Scouts of America will procure on

you are deﬁned as investigative consumer reports. These reports will be procured in connection with your

application to serve as a volunteer, and additional reports may be procured at any time during your service

as a volunteer in order to evaluate your continued suitability for volunteer service. The reports may include

information on your character, general reputation, personal characteristics, and mode of living.

Under section 1786.22 of the California Civil Code, you may inspect the ﬁle maintained on you by LexisNexis,

during normal business hours and with proper identiﬁcation. You may also obtain a copy of this ﬁle, upon

submitting proper identiﬁcation and paying the costs of duplication, by appearing at LexisNexis ofﬁces

in person, during normal business hours and on reasonable notice, or by certiﬁed mail upon making a

written request. You may also receive a summary of the information contained in this ﬁle by telephone.

LexisNexis will provide trained personnel to explain any information furnished to you and will provide a

written explanation of any coded information. This written explanation will be provided whenever a ﬁle

is provided to you for visual inspection. If you appear in person, you may be accompanied by one other

person of your choosing, who must furnish reasonable identiﬁcation.

For Applicants in California, Minnesota, and Oklahoma Only

You have the right to request a free copy of any report procured on you. If you wish to receive a free

copy of any report procured on you, check the box below.

 I request a free copy of any report procured on me.

New York

As explained above, a consumer report will be requested in connection with your application, and additional

consumer reports may be requested during the course of your service with the Boy Scouts of America.

You have the right, upon request, to be informed whether or not a consumer report was requested and,

if a consumer report was requested, of the name and address of the consumer reporting agency that

furnished the consumer report.

First name (No initials or nicknames) Please print. Middle name Last name Sufﬁx

Signature of applicant Date Unit No.

My signature below indicates that I have read, understand, and accept the accompanying disclosures and acknowledgments.

DISCLOSURE/AUTHORIZATION FORM

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Pack Troop Team Crew Ship

Unit

No.

    



E-mail address Work

(Select one)

 Home

Fast Start training

African American

Caucasian/White

Native American

Hispanic/Latino

Alaska Native

Paciﬁc Islander

Asian

Other

Yes



Youth Protection training



 

New leader

 

Former leader

Signature of applicant Date

Signature of unit committee chairman Date

(ACCEPTED) Signature of Scout executive or designee Date

Signature of Scout executive or designee Date

Signature of chartered organization head or representative Date

Boys’ Life

subscription



4001

UNIT SCOUTERS (Fill in the circle.)

The information obtained in this form is for the

internal use of the BSA only.

TRANSFER FROM: COUNCIL NO. TYPE OF UNIT UNIT NO.

Please print one letter in each space—press hard; you are making three copies.

Have you completed:

Country Mailing address City State Zip code

First name (No initials or nicknames) Middle name Last name Sufﬁx

/ /

Date of birth (mm/dd/yyyy) Ethnic background: Driver’s license No. State

EXPIRE DATE















Gender Social Security number (required) Occupation Employer

Home phone Business phone Ext. Cell phone

- -- -

/ /

Country Business address City State Zip code

- - X

1. Scouting background.

Position Council Year

__________________________________

2. Experience working with youth in other

organizations.

__________________________________

3. Previous residences (for last ﬁve years).

City State

__________________________________

4. Current memberships (religious, community,

business, labor, or professional organizations).

__________________________________

5. References. Please list those who are familiar

with your character as it relates to working

with youth. References will be checked when

necessary.

Name ________________________________

Telephone (_____) _______________________

Name ________________________________

Telephone (_____) _______________________

Name ________________________________

Telephone (_____) _______________________

6. Additional information. Yes or No

(Mark each answer.)

a. Do you use illegal drugs?

b. Have you ever been convicted of

a criminal offense? (If yes,

explain below.)

c. Have you ever been charged with

child neglect or abuse?

d. Has your driver’s license ever

been suspended or revoked?

(If yes, explain below.)

e. Other than the above, is there any

fact or circumstance involving you

or your background that would call

into question your being entrusted

with the supervision, guidance,

and care of young people? (If yes,

explain below.)

__________________________________



I understand that:

a. The information that I have provided may be veriﬁed, if necessary, by contacting persons

or organizations named in this application, or by contacting any person or organization

that may have information concerning me, or by conducting a criminal background check.

I hereby release and agree to hold harmless from liability any person or organization

that provides information. I also agree to hold harmless the chartered organization, local

council, Boy Scouts of America, and the ofﬁcers, employees, and volunteers thereof.

b. In signing this application, I have read the attached information and apply for

registration with the Boy Scouts of America. I agree to comply with the Charter and

Bylaws, and the Rules and Regulations of the Boy Scouts of America and the local council.

I afﬁrm that the information I have given on this form is true and correct. I will follow the

Youth Protection guidelines.

APPROVALS FOR UNIT SCOUTERS

We are unaware of anything contrary to the information stated in this application. This application has been reviewed

according to BSA procedures and this applicant meets the leadership qualiﬁcations of the Boy Scouts of America:

Retain on ﬁle for three years.

Registration fee Boys’ Life fee

$ .

TERM MONTHS

U S

Council/district position

District name

APPROVAL FOR COUNCIL AND DISTRICT SCOUTERS

We are unaware of anything contrary to the information

stated in this application. This application has been reviewed

according to BSA procedures and this applicant meets the

leadership qualiﬁcations of the Boy Scouts of America:

- -

/ /

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

If applicant has an unexpired membership certiﬁcate; registration may be accomplished in this unit by paying $1 for processing the transfer. Mark and attach certiﬁcate. It will be returned by the council.

M F

ADULT APPLICATION 524-501A

1 2 3 4 5 6 7 8 9 0 A B C D E F G H I

This form is read by machine. Please print the numbers and letters as shown:

LOCAL COUNCIL COPY

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***Select One***