Form 34405 Gec - Merit Badge Counselor Information - 2016
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1
2Boy Scouts of America Glaciers Edge Council
MERIT BADGE COUNSELOR INFORMATION
(Please type or print legibly.)
Primary phone*
Name*
Cell
Work
Home
Address*
Work
Other phone
Home
Cell
City/state/zip*
Other phone
Home
Cell
Work
I do not have email.
Email address*
Age
District
Unit:
Troop
Team
Crew
Ship No.
BSA ID
I am not a liated with a district.
I am not a liated with a unit
*Required eld.
Primary phone and email address indicate how Scouts should contact you.
To qualify as a merit badge counselor, you must
As a merit badge counselor, I agree to
Follow the requirements of the merit badge, making no
Be at least 18 years old and of good character.
deletions or additions, ensuring that the advancement
Be registered with the Boy Scouts of America (position code 42).
standards are fair and uniform for all Scouts.
Complete Youth Protection Training.
Have a Scout accompanied by his buddy during all
Be recognized as having the skills and education in the merit
instructional sessions.
badge subject covered and hold any required quali cations
Keep my Youth Protection training current.
and training as outlined in the Guide to Safe Scouting or the
Renew my registration annually if I plan to continue as a merit
Guide to Advancement - or use others so quali ed.
badge counselor.
Be able to work with Scout-age boys.
Merit Badges
Add (A)
For each merit badge, list quali cation(s) that support your request.
For more than four merit badges,
Drop (D)
Quali cations could include college degrees, formal training certi cates,
attach additional sheets.
positions held, and speci c life experiences.
1.
2.
3.
4.
A = Adding a new merit badge that you will counsel to the roster. D = Removing your name from the roster for this merit badge.
Complete the following:
This is a new application ( rst time to register as a merit badge counselor).
Attach this form to the BSA Adult Application, indicating position code 42.
I no longer wish to serve as a merit badge counselor.
Council Approval:
This is an update to an existing list of merit badge subjects.
Name (print)
Youth Protection training date
Position
(Attach copy of the current certi cate.)
Date
I agree to:
Abide and follow all provisions of the Merit Badge Counselor Orientation, Supplemental Adult Leader Training
Work with all Scouts
Remain current in my Youth Protection Training at all times while serving as a Counselor
Allow my personal contact information (name, address, phone, and e-mail) to be shared with Scouts and their Scoutmaster.
I plan to serve as a merit badge counselor for this event or outside organization:
Signature
Date
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