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 Sufx
/ /
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
Pacic Islander
Asian
Other
Preferred nickname:
○
○
○
○
○
○
○
○
○ ○
○
○
○
○ ○
524-501
○
YPT completion certicate 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 certicate:
Council No.:
Unit No. or
District name:
○
Ship
OR
District name
U
S
A
U
S
A
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 satised 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 satised 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 afrm 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 afrm 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
trafc 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 certicate, registration may be accomplished at no charge by transferring the registration
or multiple registering.
$
$
TURN ON "CAPS LOCK" WHEN FILLING OUT FORM