Bsa Youth Member Application (Page 5 of 6) in pdf

BSA YOUTH MEMBER APPLICATION

YOUTH INFORMATION

First name (No initials or nicknames)

Middle name

Last name

Suffix

Preferred nickname

Country

Mailing address

City

State

Zip code

U S A

Home phone

Date of birth (mm/dd/yyyy)

Grade

Ethnic background:

Gender:

™

Black/African American

Native American

Alaska Native

Male

Female

School

™

Caucasian/White

Pacific Islander

Asian

™

Boys’ Life subscription

Hispanic/Latino

Other

™

PARENT/GUARDIAN INFORMATION

™

Mark here if address is same as above.

Mark here if you are the Lion or Tiger adult partner.

Mark here if the Lion or Tiger adult partner is not living at the same address and complete and attach an adult application.

Select relationship:

™

Parent

Guardian

Grandparent

Other (specify)

First name (No initials or nicknames)

Middle name

Last name

Suffix

Preferred nickname

Country

Mailing address

City

State

Zip code

U S A

Home phone

Date of birth (mm/dd/yyyy)

Occupation

Employer

Gender:

™

Male

Female

Cell phone

Business phone

Ext.

Previous Scouting experience

I have read the attached information for parents and approve the

application. I affirm that I have or will review “How to Protect Your

Children From Child Abuse: A Parent’s Guide.”

Parent/guardian email address

Signature of parent/guardian

Date

To be completed by unit

If applicant has unexpired membership certificate, registration may be accomplished at

no charge by transferring the registration.

Signature of unit leader (or designee)

Date

™

Enter membership number

Transfer application

from unexpired certificate:

Unit type:

™

Cub Scout

Boy

Venturing

Sea Scout

Lone Cub Scout

Pack

Scout

Crew

Ship

™

Transfer from

Unit

™

Unit No.:

Lone Boy Scout

Pack

Troop

council number:

type:

™

Crew

Ship

Unit No.:

For pack registration select one:

™

Lion

Tiger

Wolf

Bear

Webelos

Registration fee $

Boysʼ Life fee $

UNIT COPY

524-406

Bsa Youth Member Application Page 5

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