2021 National - Washington Crossing Council, BSA Adult Contingent Leader Application

For Jamboree Contingent Troop: Scoutmaster, 1st Asst SM, 2nd Asst SM, 3rd Asst SM, Crew/Ship Advisor/Skipper, Associate Advisor/Mate

Please type or print neatly and as completely as possible. Use a separate page (if needed).

PROPER NAME: ______BSA ID ______

NICKNAME: ______BEST PHONE NUMBER: ______

GENDER: (check one) ___ Male ___ Female DATE OF BIRTH ______

Contingent Leadership Positions Applying for (select one or more):

Troop: ___ Scoutmaster ___ 1st Asst. SM ___ 2nd Asst. SM ___ 3rd Asst. SM

Crew/Ship: ___ Advisor/Skipper ___ Associate Advisor/Mate

OCCUPATION: ______

ADDRESS: (Street, Town, State, Zip Code)

SCOUTING LEADERSHIP EXPERIENCE CURRENT LEADERSHIP TENURE UNIT TYPE UNIT DISTRICT POSITION NUMBER

Other Adult Leader Positions Held in Scouting (list with most current first): OTHER ADULT SCOUTING TENURE UNIT TYPE UNIT DISTRICT/COUNCIL LEADERSHIP POSITIONS NUMBER

LEADER SPECIFIC TRAINING Date Completed Date Completed Youth Protection Leader Specific Hazardous Weather IOLS

SCOUTING AWARDS EARNED/RECOGNIZED Describe award, include dates (IE: Eagle , Silver Beaver, ) Scouting Awards Date Earned Scouting Awards Date Earned

NATIONAL/WORLD ATTENDED As a youth and/or adult Jambo Year Youth/Adult Position(s) Held

LONG TERM EXPERIENCE 5 days or longer Date Camp/Location (List most current first) Duration Position Held

HIGH ADVENTURE EXPERIENCE BSA or Local Council High Adventure Bases Date Base/Location (List most current first) Duration Position Held

OTHER ADULT LEADER TRAINING PERTINENT TO THIS APPLICATION (IE: CPR/AED, Wilderness First Aid, Red Cross First Aid, etc.) Training Date Certification? Expiration Date

ADULT LEADERSHIP POSITIONS HELD OUTSIDE OF SCOUTING (School, Church, Civic, Trade) Dates (from/to) Organization Position(s) Held

PHYSICIAL ABILITY AND CONDITIONS Attendance at the Jamboree will require walking long distances on natural surfaces, sleeping on a basic cot in a tent, and bearing all types of weather conditions as it will be very hot and humid. Therefore, you must be physically fit. List any conditions that may limit your activity at the Jamboree.

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EXPLAIN WHY YOU ARE APPLYING FOR THE DESIGNATED JAMBOREE ADULT LEADERSHIP POSITION Use additional page if needed

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REFERENCES (3) Name Relationship Contact information (Phone, Email) Committee Chair or Charter Org Rep Non-Relative and Non-Scouting

I certify that the information I have provided on this application is true to the best of my knowledge

I agree to follow, abide by, and enforce ALL rules, regulations and policies of the of America, the 2021 National Jamboree, and Washington Crossing Council, BSA.

______Signature Print Date

This page for application’s additional information or comments