Merit Badge Counselor Application Form - Heart Of America Council
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1
2Heart of America Council
Boy Scouts of America
M
B
C
A
ERIT
ADGE
OUNSELOR
PPLICATION
YEAR ________
Renew _______
*As a New Counselor ______ I have attached an Adult Application as required by National BSA.
Please print or type the following information. List your name as it shows on your BSA registration.
Name ________________________________________________ Unit# _________ District _____________________
Address __________________________________________________ Home Phone (
) ____________________
City ________________________________ State ________ Zip ____________Date of Birth ____________________
Occupation ________________________________ E-mail Address _________________________________________
I am currently registered with the BSA as (position) _______________________________________________________
Are you an Eagle Scout? Yes __________ No __________
If yes, what is your Eagle Rank date? _______________
All Merit Badge Counselors must be registered members of the Boy Scouts of America. Even if you are already
registered in another position, you must still complete a BSA Adult Application (#28-501F) form with the
Position Code “42” (no charge). Note: Effective April 1, 2003, the Social Security Number on all adults is required by
the National Boy Scouts of America. Effective June 1, 2010, all adults are required to provide proof of Youth Protection
Training with their applications.
To qualify as a merit badge counselor you must:
1. Be at least 18 years old.
2. Be proficient in the merit badge subject by vocation or avocation.
3. Be able to work with Scout-age boys.
4. Be registered as a Merit Badge Counselor with the Boy Scouts of America. (Submit Adult BSA Application with
your Merit Badge Counselor Application.)
5. Attend Merit Badge Counselor Orientation
.
I attended Merit Badge Counselor Orientation on: Date______________
.
6. Attend Youth Protection Training – Please attach a copy of your card
I received Youth Protection Training on: Date ______________
The Boy Scout Handbook instructs the Scout to meet with you, before he starts to establish a mutual
understanding of the requirements and his commitment to complete those requirements.
By signing the back of this form, you agree to the following standards:
As a Merit Badge Counselor, I will:
1. Examine the latest revision of the BSA Merit Badge pamphlet of each Merit Badge I select on the reverse side of
this form.
2. Require the Scout to complete all and only all of the requirements.
3. Counsel the Scout to:
a. Keep his appointment.
b. Be in uniform.
c. Bring a legible filled out Merit Badge Card signed in ink by his unit leader or designee.
d. In keeping with BSA Youth Protection Guidelines, have multiple Scouts/Adults at every counseling session.
Notify the District Advancement Chairman if I can’t serve as a Merit Badge Counselor any longer this year.
4.
Renew my Merit Badge Counselor application every year. If I let my membership lapse I will complete a new
5.
.
BSA Adult Application for Merit Badge Counseling
Staack:mbcapp2015
9/22/2014
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