2021 National Jamboree - 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 SCOUTING 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 Scout, Silver Beaver, Wood Badge) Scouting Awards Date Earned Scouting Awards Date Earned
NATIONAL/WORLD JAMBOREES ATTENDED As a youth and/or adult Jambo Year Youth/Adult Position(s) Held
LONG TERM CAMPING 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 Boy Scouts of America, the 2021 National Jamboree, and Washington Crossing Council, BSA.
______Signature Print Date
This page for application’s additional information or comments