Adult In Camp Compliance Form - Boy Scouts Of America - Texas
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1SAM HOUSTON AREA COUNCIL
BOY SCOUTS OF AMERICA
ADULT IN CAMP STATE COMPLIANCE FORM
Please Print.
All information on this form is required.
Full Legal Name: ___________________
_______________________
________________________
Full
Last Name:
Full First Name
Middle Name
Birth date: ______________________
SSN: __ __ __ __ __ __ __ __ __
(mm/dd/yyyy)
Home Address: ________________________________City: _______________________ State: _____ Zip: ____________
Daytime Phone: ______________ Cell Phone: ________________ Email: _______________________________________________
Unit Type:
Unit Number: _______ District: ________________ Council: ________________________
(Pack/Troop/Crew) __________
1. Which camp are you attending?
District Day Camp: District Name ______________________
Day Camp Dates ___________________________
Bovay Resident Camp: Session: 1 2 3 4 5 6 7 8
Walter Horseshoe Bend Summer Camp: Week:
1
2
3
4
5
6
7
Cockrell River Camp Summer Camp: Week:
1
2
3
4
5
6
7
Rough Riders: Week:
1
2
3
4
5
6
7
Super Troop: Week:
1
2
3
4
5
6
7
Winter Camp
2. Experience working with youth in other organizations: __________________________________________________________
______________________________________________________________________________________________________
3. Previous Residences (last 5 years): ____________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4. References.
Please list those who are familiar with your character as it relates to working with youth. References will be checked when necessary.
Name: ___________________________________________ Phone: ___________________ Phone: ___________________
Name: ___________________________________________ Phone: ___________________ Phone: ___________________
Name: ___________________________________________ Phone: ___________________ Phone: ___________________
5. Additional information. Mark each answer Yes or No. (* For items marked yes, attach a letter of explanation.)
Do you use illegal drugs?
Yes
No
Have you ever been convicted of a criminal offense?
Yes*
No
Have you ever been charged with child neglect or abuse?
Yes
No
Has your driver’s license ever been suspended or revoked?
Yes*
No
Other than the information above, is there any fact or circumstance involving you or your background that
Yes*
No
would call into questions your being entrusted with the supervision, guidance, and care of young people?
6. Background check. A criminal and sexual background check is required annually by the State of Texas and will be conducted by
the Sam Houston Area Council.
I agree to a criminal and sexual background check.
Yes
No
7. Signature: ____________________________________________________ Date: _______________________________________
revised Oct 2012
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