BSA ADULT MEMBER APPLICATION

BSA ADULT MEMBER APPLICATION

Troop Devon 50 & Valley Forge Pack 81
For which unit are you registering?
Name

First name Middle nameLast nameSuffix
Preferred nickname
Address

Home address

Street Address Line 2

CityState

Zip code
Country
Primary phone
Format: (000) 000-0000.
Alternate Phone
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Drivers License Number
Drivers License State
Gender
Social Security No. (required)
Occupation
Employer
Work Address

Business address

Street Address Line 2

CityState

Postal / Zip Code
Work Country
Scouting Position code
SA for Assistant Scoutmaster / 91 for Parent Volunteer
Scouting Position Title
Assistant Scoutmaster or Parent Volunteer
Are you an Eagle Scout?
Date Earned

MonthDayYear
Date
BSA ID
(if already registered)
Applicant Email
example@example.com
Email address (Select one)
Check here if you'd like a:
A Devon 50 Hold Harmless Agreement and BSA Activity Consent form is required to be submitted every year for all registered Scouts and Parents participating in Scouting events. Please use the following links to complete and sign both documents for each Scout and Parent.

Devon 50 Hold Harmless

BSA Activity Consent Form

Medical Forms (A&B and C is only for Camp)

- Fill in this form and print and hand it in to Membership
I have read and affirm 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.
Type your initials here
I affirm that the information contained in this application is true and accurate to the best of my knowledge and belief.
Type your initials here
Signature of Adult Applicant
Date

MonthDayYear
Date
Unit Number
All questions MUST be answered. Write NONE if applicable.
1. Scouting Background (Position/Council/Year)
Enter Position/Council/Year for each position you've held.
2. Experience working with youth in other organizations:
Enter Position/Council/Year for each position you've held.
3. Previous Residences (past 10 years):
4. Current Memberships (religious, community, business, labor or professional):
5. Three References (Name and Phone)
6. Additional Information.

(Mark Each Answer)
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?
Yes or No?
Explain (if necessary)
Do you use illegal drugs or abuse alcohol?
Yes or No?
Explain (if necessary)
Have you ever been arrested for a criminal offense (other than minor traffic violations)?
Yes or No?
Explain (if necessary)
Has your driver's license ever been suspended or revoked?
Yes or No?
Explain (if necessary)
Have you ever been investigated for, accused of, or charged with abuse or neglect of a minor child?
Yes or No?
Explain (if necessary)
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?
Yes or No?
Explain (if necessary)
Additional Disclosures & Background Check Authorization
Name
List any other names used
Birth Date

MonthDayYear
Date
Unit and Number
Signature
Date

MonthDayYear
Date
Should be Empty:

BSA ADULT MEMBER APPLICATION

Additional Disclosures & Background Check Authorization