Merit Badge Counselor Application Form printable pdf download

HEODORE

OOSEVELT

OUNCIL

COUTS OF

MERICA

MERIT BADGE COUNSELOR APPLICATION

District you are applying to be a counselor in (check one):

Iroquois _____ Pequott _____ Rough Rider _____ Shelter Rock ______

Name (print) _____ ____________________________________________________ Birth Date _________________________

E- mail ___________________________________ Phone home (

) _______-_________ work (

) _______-_________

Address ____________________________________________ Town _____________________State _____ Zip___________

I am currently registered in the following unit or District position.

_____________________________________________________________________________________

I have read the merit badge pamphlet(s) for my chosen subject(s) and I wish to apply as a merit badge counselor. I have also

read the Merit Badge Counselor Agreement on the reverse side of this application. As a counselor I will perform a distinct

service to the youth of my community by helping them discover new vocational or avocational interests. I will not only ascertain

that the Scout meets the requirements of the merit badge, but I am also prepared to counsel and advise him in the subject. I

have experience in the subject(s) in which I seek appointment and I will submit evidence of my qualifications if necessary.

Signature ______________________________________Date

MERIT BADGE

DESCRIPTION OF QUALIFICATIONS

______________________________________________________________________________________________

All merit badge counselors must be registered. Individuals not already registered with the Theodore

Roosevelt Council should attach a signed and completed Boy Scouts of America Adult Application (No. 524-

501A) to this application

. Individuals registering as a merit badge counselor only are not required to pay. However, for a

nominal fee of $15.00 you will also be registered as an Adult Scouter with all the privileges of membership which include liability

insurance and Scouting magazine. These publications will keep you updated on developments in the merit badge program.

Boy’s Life magazine is also available for an additional fee of $12.00 annually.

NOTE: You are not eligible to begin counseling Scouts in the above badges until you receive confirmation of your approval from

your District Dean of Merit Badge Counselors.

CHECK ONE:

[

] I am currently not registered and wish to register only as a counselor. Form 524-501A is attached. (No fee is required).

[

] I am currently not registered and wish to register additionally as a Scouter. My fee and Form 524-501A are attached.

[

] I am already a merit badge counselor adding an additional merit badge (Form 524-501A is not needed).

[

] I am a merit badge counselor deleting the merit badges listed above (Form 524-501A is not needed).

[

] I am currently registered with the council but applying to be a merit badge counselor for the first time (Form 524-501A is not

needed).

Mail and make registration check payable to: Theodore Roosevelt Council, B.S.A.

544 Broadway

Massapequa, NY 11758-5010

(See Reverse Side)

Rev 5/22/2010

Merit Badge Counselor Application Form

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