Page 1 of 3 Pack 1232 - Selkirk Volunteer Fire Company No 2 201572536 APPLICATION DETAILS Application ID 201572536 Parent / Guardian MemberID ID 141432432 Applicant Member ID 141432433 Applied to Organization Twin Rivers Council 364, Fort Orange 01, Pack 1232, Selkirk Volunteer Fire Company No 2 Submitted Date 12/17/2024 00:00:00 Current Status Completed Current Status Date 12/16/2024 21:28:49 BSA Youth Registration (Trad.) $85.00 Council Fee $40.00 Administrative Fee OLR $3.75 1 STEP 1: YOUTH INFORMATION First Name Jorden Last Name Perez-Tran Age 5.5y Gender Male Grade Kindergarten / Grade Prior to the First Grade Ethnic Background Hispanic/Latino Country USA Address Line 1 22 Fairlawn Drive Address Line 2 22 Fairlawn Drive City Selkrik State NY Zip Code 12308 Personal and Confidential for Authorized BSA Use Only Page 1 YOUTH APPLICATION
Page 2 of 3 Pack 1232 - Selkirk Volunteer Fire Company No 2 201572536 2 STEP 2: PARENT INFORMATION First Name Phuong Middle Name Last Name Perez-Tran Age 35y Gender Female Ethnicity Asian Relationship to youth Son of Country USA Address Line 1 22 Fairlawn Drive Address Line 2 22 Fairlawn Drive Address Line 3 City Selkrik State NY Zip 12308 Phone Number 001 (518) 291-0660 Email Address phuongperez@gmail.com Personal and Confidential for Authorized BSA Use Only Page 2 YOUTH APPLICATION
Page 3 of 3 Pack 1232 - Selkirk Volunteer Fire Company No 2 201572536 2 STEP 3: ADULT PARTNER INFORMATION First Name Middle Name Last Name Age y Gender Ethnicity Relationship to youth Country Address Line 1 Address Line 2 Address Line 3 City State Zip Phone Number Email Address Personal and Confidential for Authorized BSA Use Only Page 3 YOUTH APPLICATION
Original PDF: Jorden Perez-Tran Application.pdf