Fill - Free fillable BSA ADULT APPLICATION PDF form

Signature of applicant Date

Email address Work

(Select one)

Home

Yes No

Scout 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

Scout 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.

TURN ON "CAPS LOCK" WHEN FILLING OUT FORM

MDSC = "023"

CLEAR FORM

SAVE FORM

PRINT FORM

COUNCIL COPY

BACKGROUND CHECK

AUTHORIZATION

(Please print)

Name: First __________________________ Middle ____________ Last _________________________ Suffix ______

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

Date of birth: ___________________________

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

subsidiaries, affiliates, other related entities, successors, and/or assigns (the “Company”), to procure consumer

report(s), which may include criminal background check(s) and/or investigative consumer report(s) (as defined by

applicable California law), 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 Additional

Disclosures (all of which I have received separately from the Company). I have reviewed and understand the

information, statements, and notices in the Background Check Disclosure and the Additional Disclosures, as

well as this 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 may include criminal background check(s), during my volunteer relationship without

providing additional disclosures or obtaining additional authorizations. Except as otherwise prohibited by appli-

cable law, I consent to and authorize the Company to share this information with Company’s current or prospec-

tive clients, customers, others with a need to know, and/or their agents 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 only: 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 ______________________

Unit Type

& Number

Signature of applicant Date

Email address Work

(Select one)

Home

Yes No

Scout 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

Scout 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.

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