514-017 - Supernova Awards Mentor Information Form
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1Supernova awardS Mentor InForMatIon
Name ________________________________________________________________________ Age _____________
Business phone (_____) ___________________________
Home phone (_____) ___________________________
Mobile phone (_____) _____________________________
Email _______________________________________
Address _______________________________________________________________________________________
City _____________________________________________ State _____________ Zip code ___________________
to qualify as a Supernova awards mentor, you must
as a Supernova awards mentor, I agree to
• Be at least 21 years old.
• Follow the requirements of the Supernova award,
• Be proficient in the Supernova topics by vocation,
making no deletions or additions, ensuring that the
avocation, or special training.
award standards are fair and uniform for all youth.
• Be able to work with Scout-age youth.
• Have a Scout or Venturer with a buddy or a second
• Be registered with the Boy Scouts of America.
adult over age 18 present at all instructional sessions.
• Renew my registration annually if I plan to continue as
• Be current with BSA Youth Protection training.
a Supernova awards mentor.
• Follow all protocols outlined in BSA Youth Protection training.
avocation
Special training
vocation
Is this subject in line with your job,
Do you follow this subject as a
If not, do you have any special training
business, or profession? If yes, give
hobby, having more than a “working
or other qualifications for this subject?
brief information on the reverse side.
knowledge” of the requirements?
If yes, give brief information on the
If yes, give brief information on the
reverse side or in an attachment.
reverse side or in an attachment.
List Supernova topics you are
qualified and willing to mentor here.
___________________________________________________________________________________________
1.
___________________________________________________________________________________________
2.
___________________________________________________________________________________________
3.
___________________________________________________________________________________________
4.
___________________________________________________________________________________________
5.
___________________________________________________________________________________________
6.
___________________________________________________________________________________________
7.
Attach additional sheets if necessary.
CHeCK one:
■
I wish to work only with ______________________.
This is a (check one)
■
Pack
■
Troop
■
Crew
Unit No.
I wish to work with units in the following programs:
Pack
Troop
Crew
■
■
■
■
Signature _____________________________________________________________ Date ____________________
note: The BSA Adult Registration Application must be attached.
Council approval by _____________________________________________________ Date ____________________
514-017
2012 Printing
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