MERIT BADGE COUNSELOR REGISTRATION
Document Sample
OLD NORTH STATE COUNCIL BOY SCOUTS OF AMERICA
MERIT BADGE COUNSELOR REGISTRATION
Name Age Home phone
Address Business phone
City State NC Zip
Scouting District Battlefield
To qualify as a merit badge counselor, you must: As a merit badge counselor, I agree to:
Be at least 18 years old. Follow the requirements of the merit badge, making no deletions or additions,
Be proficient in the merit badge subject by vocation or avocation ensuring that the advancement standards are fair and uniform for all Scouts
Be able to work with Scout-age boys. Have two or more Scouts present at all instructional sessions.
Be registered with the Boy Scouts of America. Renew my registration every two years if I plan to continue as a counselor.
Please list your qualifications to counsel the merit badge. Qualifications may be based on your job, a
hobby, or some form of special training or certification, but should reflect true expertise in that area.
Please note minimum qualifications for selected badges under NOTES below & cite certification
LIST MERIT BADGE TITLES HERE
NOTES Counseling for Rifle or Shotgun Shooting merit badges must hold an NRS Instructor’s Certificate or NC Hunter Safety Instructor’s Certificate.
Lifesaving merit badge must be counseled under the supervision of a Red Cross, YMCA, or BSA aquatics instructor.
It is preferred that First Aid merit badge counselors hold a current professional certification such as EMT, RN, or Quick-Response Team member
of fire department, but as a minimum, counselors must hold the equivalent of a current Red Cross Standard First Aid Instructor certification.
Counselors of the Whitewater merit badge must be certified as an Advanced Canoeing Instructor by the Red Cross, American Canoe
Association, American Whitewater Affiliation, or United States Canoe Association.
Counselors of the Climbing merit badge must be a C.O.P.E. instructor , or have a BSA National Camp School certification in C.O.P.E.
Camping and Cooking merit badges must be signed off by Scoutmasters & Assistant Scoutmasters only – registration is not necessary.
CHECK ONE: CHECK ONE:
I wish to work only with ____103____________
(Unit Number)
I am currently registered as _______________________
(Positition/unit/district)
I wish to work with all units I am not currently registered with BSA.
Please consider working with all units if the I have completed the reverse side of this form.
merit badge is not a commonly earned one.
Signature _______________________________________________________ Date ________________________________
Applicant
WE WILL CONTACT YOU IF THERE IS ANY PROBLEM WITH YOUR APPLICATION
OTHERWISE, YOU WILL BE ENTERED IN THE MERIT BADGE COUNSELOR DATABASE
OLD NORTH STATE COUNCIL BOY SCOUTS OF AMERICA
If you are not currently registered with the Boy Scouts of America, you must provide the following in order to be registered with the BSA as
a merit badge counselor.
Occupation, employer, and business address:
Years at this U.S. Citizen?
. employment Sex Yes No
Driver’s License No. State NC Expiration
1. Scouting background 6. Additional information
Position Council Year a. Do you use illegal drugs? Yes No
b. Have you ever been convicted of a criminal offense? Yes No
c. Have you ever been charged with child neglect? Yes No
d. Has your driver’s license ever been suspended or Yes No
2. Experience working with youth in other organizations? revoked? If yes, explain below
e. Other than the above, is there any dfact or circumstance Yes No
involving you or your background that would call into
question your being entrusted with the supervision,
guidance, and care of young people? (If yes, explain below)
3. Previous residences (for last 5 years)
City State
I understand that:
a. The information that I have provided may be verified by contacting
persons or organizations named in this application, or by contacting any
person or organization that may have information concerning me. I
4. Current memberships (religious, community, business, labor, hereby release and agree to hold harmless from liability any person or
or professional organizations) organization that provides information. I also agree to hold harmless the
local council, Boy scouts of America, and the officers, employees, and
volunteers thereof.
b. In signing this application, I affirm that the information I have given is
true and correct.
5. References. Please list those who are familiar with your character as it
relates to working with youth.
References will be checked when necessary XX
XX________________________________________________________
Signature of Applicant Date
Name Lee Hubbard, Scoutmaster 103 643-1127
Name
Name
APPROVALS:
To the best of our knowledge, this merit
badge counselor applicant meets the leader-
ship standards of the Boy Scouts of America
________________________________ ________________________________ ________________________________
District Advancement Chairman Council Advancement Chairman Scout Executive
Date: ______________ Date: ______________ Date: ______________
