TOil ADULT APPLTCAI Thlr appllcatm ls also avallablc h Spanl$. E3b sollctild tambl6n ccu dbpmFb en espailol. MtsstoN The mission of the BSA is to prepare young people to make ethical and moral choices overtheir lifetimes by instilling in them the values of the Scout Oath and Scout [aw. Your pafiicipallon ln the BSA can help youth become better citizens- Adult leaders serue as important rcle models foryouth in the BSA and this application aids the chartercd organizatlon ln selectlng quallfted adult volunteer leaders. YOUTH PROTECTION TRAINING GRIMII.IAL BACKGROUND CHECK* All adult applicants are requlred to take ln order to complete the aduh application thls training in order to complete the adult prroess, you wlll need to rcview the difier- applletlon proc€ss. Go to my.scoudng.org ent disclosureo that have been sWarety to create an accornt and take the train- prcvided to you. The separate authorlzatlon ing online, or contact your local oounc-il for form must be signed and retum€d $’hsn classrcom tralning. lnclude a copy ol your yousubmityourapplicailon. _
completion cer$ftcate with thls application. EXCERPT FROM THE DECLARATION OF RELIGIOUS PRINCIPLE The BSA malntalns that no member can grow lnto the best kind of citlzen without rccognfuing an obltgatton to God and, therefore, recognlzesthe rcllgious element ln the trcining of the memben but it is ablutely nonsectarlan ln fts attitude toward that religtous tnining, lE pohcy is fluf ttro home aN organization or group with whlch . the memb* ls connected shall glve defrnite attention to rellglous life. Onty percons willing to subscriDe to lhese proceptr. fiom the Declantlon of Beligious Prlnclple and the Bylaws of the BSA sDalt be entitled to reglster. All adult leaders agrce to comply with the Scouter Code of Gonduct. httrs//nmir.scouting.o.rglhealth -and -safety/g uidel ines-policies/ *The thrpe differcnt bac{cgrcund check forms mugt be torn off and each separately given to the applicant gKu 6dr5il8 BOY SCOUTS OF AMERICIf ,iltlJl$$Llf[lil, 524-501 2@Pdnling
lradcr Rcqulnnnnb Whal lt lh BSA Prognm? The BSA ls operr to all who meet the requlrements, and ‘eaders are selocled lhe 8SA program b oufihed ln lhs offichl publhatlons of he BSA Adivltles based on lndividual merit,Adult leaders must possess he moral, edratonal’ lhat are no{ ln these 8SA publhrtons arc not a part ol ths Scoutrng program. and omotonal gualities trat the BSA deems necessary lor posluve lsa&rship Leadors must nol alhw youh membcm s ptogram parilspanb to engage ln to youth. They must also: any unaulhorlzod or prohiblted actvflns. . Abide by tl€ Scoul 0alh, Sout Law, an a d S t c @ outer Code ol Conducl, The flalnlnl lor llaw lordrn Scouter Code 0f Corducl can beJound The SA b c0mmittod b yox srrccsss as a volunher whlle seMm y$]u s8r6WFft sa-sco{tgr-co{hd-D0{fultl. . peopla. Io help you be succe*{ul, lhere are trainhg matorials dsslgn€d r Subscribe to the precepls of he Dedatatim ol ReliglflJs Prlnciple’ lor pu. Tra:ning ;oc{xtrcos aro available thrulryh yflJr local comcil and al Reside within the USA or a U.S. tertllory, or be a U.S. cilizen residittg mv.scou,ilno-olg. . dltside uE usA. r B€ 2l yeus ol ags or older lot primary leadership pmitiorn. llhatllakn r Trrhal Lr&r? ‘ B G e o m 1 p 8 l e y l e e u Y s o o ul l l r a P oe ro o te r c o th H n e l t a lo in ra in s g s b (Y b P n T t ) M be a fo n re s l a ilp pp l p ic o a s t l i i o lo n t ts is . pmcesod Y sp ou a c a il r i o c c b o a n in si i d n e g r o f d o r a y o tr u a r , n p e o d s i l l e in ad e a r n d w h h e a n ve y o c u u n h e a n v t e Y c o o u m h p P lo r t d €d ec le lh a n d e ir r a p in o in s g it . on’ and renaw bainlng as required by SolnS to ry,Soodbg.orq and creating . an account. Youth Protocton BolnrWillt Yourn r R pr e o v c ie s w ss t a h n e d d c is o c m lo p s le tr t g e l a n n lo d r $ m g a n t im a B re a l d at t e g d r o t n o d t B C h B e S c A k S A b th a o c r k iz g a ro li u o n n d l c o h m €ck ‘ a C n h y il w d h a e b m us . e o v is e n a s in f l S ir c u o B u t p n r g o . b F lo o m r h ln a t a r r d $ o o c n $ , t y th , € an B d S A u n co lo n t d u n n u a e t s d y l0 , l c t r c €a a le n mar Take leader position-speclfic tralning at me.scortin0.olg. Clasrcom bsnhrs t0 abuse beyond rvhal have prevlously exi$ted in Sctutrq. tnaining may also bo available thrcugh you l0cslcouncll. It 18 t[e phlosophy ot Scflttlng lo welcomo a[ ellgltle addb, A Th ll e a B & S t A t b is a c & o r m 8 m m i u lb s d t c lo o m p p ro le v b id in \h g r a h s a P l m e t e o r c w tl l m on f m a e in n ln t g ff i a y s o p tl a n r g t o p l €o h pl a e. ngadhss ol gondot, taco, otlnlc backsotrld, $exual orlentallon’ registatim process and renew lhelr taldru as raquired. lt ls hl$tly or gsrdel g l n d d e n m t c fl c c t a a to ny n , o w tlt l c ro r t a a re q u u l l r l o [n ff g in b to a o c f c m op m t b S c c n ou h [ l n p g . ‘r ralues r Y e P c T q . n T m o s le n a d r e n . d m t o n r a e t f p i a u re t n t t s h e r rh B o S A p 3 a Y rt o c u ip tt a l P e r o ln t e S c c tm af in ro g s o a u c rc ti e v s t’ , t e g s o c t o o mplete wlYlr. $ar[fn.grgfr ainlncrwu!.flrute0tia0l. APPnOlAL SEOnRClHtllT ltll’LTS IIe chartered organization reprasentatlw ls approrsd ry he h€ad 0f he iliilrtbry Rlporflng chertered organization.All other addt leader applicatkms must bo acc0pted All persons involved in Sco{ing mut immedhtely report to hcal aufiorities and spproved Dy tre head ol the clurtered organlzeton or ihs chartred any good-hith susplchn or ballef ttnt any child is or has been physically or organizatim representatve. sexually abrned; physlcally or emotionally neglected; exposed to ary lorm Scout excculve or do8lgneo musl approve any adutts who amwgr’Tos” b l 0 h l e v l p ol c e s n e c€ ss 0 io r n h , r m ea a t n l u 0 fa r c e l x u p re o , s s a d d b i s a t n lh y j t h io r n m o o l f c s h e l x l u d a $ l m e o xp g l r o a lh p t i lo y n , o i n n h d n l e ding any Additional lnformatm questim. solicihllon, enticement, or shofling 0f obscone malerl?i. ilo person may aMicate his tepffUng rcspomihltty to any other pemon. APP8OVAT REOUIRH}-OOUTICII ANd DFTRrcI AT’ULIS Soou[ uccrtin or derllnc must accept ald apOmo all c’ouncll and Additionally, any lrnowo or nrsDccilrd rbucs or beftarhr firt mlght put a dbtricl adults. youil at rbl( rnust also be reporled to ths hcal Scout exeorlive or fie Scotb Scottt executvc or dGdgnaa most approve any adulls wio ansrver “yes’ to Flrst tl€lpline (l -844-SC0UfSl or 1-84’l-726-88n I il your Scotit execuilve or local councll cannot be reached. any Additlonel hlormalion gueslion. I M hc o c a t d l r o d o t lo tr r t d ln e l r n r g p p h l e h s a D to co n n p o r o o m cc p s l c c b w d l ll a n n d o t a b c c d c t o d m ne p l l c b b e d u ( n g t I l o m Yo d u[t . Trvo registerod adult le Y ad o e u r t s h 2 P 1 l o y t e o a c m fr o o n f a P g o o l l o d r c m e r arc regulpd at a’l chcd( hs boen o0trlnql. Souting actMtes, ittduding meelhgs.There must be a registeed female adult hader orcr 2l in sy€ty unit s$vlng lemales. A registered female adull Hralth Homrton. \bu shottld lnbrm your udt leadelshh ol any condltlon . l 0 e n a e d - e o r n o - r o re n r e 2 c 1 o m fl u h s t t b b e e tw pr e e e s n e n a t f f u rr tl a le n a y d a e c r u s v a iU nd i n y v o o u h lh in g m e le m m b a e la rs y s outh. trat might I mit your particha0on. Beloro panldpatlng ln acthlties witi your prohhlled boh lffiHo atd outside ol Scuting. unit, please lill out theAnnul Healh and ilodical Bocord, ilo.680’001,lound on wwwscouffno.or0dorms and prwide il to your unit leadershlp. These atd other layYoutr Prolsdlon policies as addressed in the talning Smd frrb. Registorod adulb gd a spocld $f5 nto. For a anbscrh{lon b and at nrn.rmuHusCmdn$Sdl-If$hGliq0l tn a S m co a u g t a tl z & in c e ir t d h e a t m he lp h s s d a il p d p r l e lc n a tl g o r n u v a n i d n t p h a e y S fi c e w s ii u n b g s c p ri r p o t g io a n m , p r i l u ce st . lill in T re o v l i e s a w r n t t a n b o o u n t l in t e re w B r S sl A o b n o o h f e th r e h e g a f l u th lo a t n o d & s l a e fe t S y f p fi o fi i n iti g o . s , t h p e l e S a c so outst Code of 0ondwt and $o SAFE Checklisl, h’hbh are awilable at IHE AIIIUAI fl/INOilAt REGISTRAIIOII FEE IS TIOIIRER’IIDABT”E. BSAPtltnoYPdlcf Scout0eth Th6 8SA protocts fie confldenilality of he names and personal inlormatbn 0t thoee who arc afliliahd wlth tho orgnnizatlon. lb commsrclal or unaulhrized 0n m an y d l r t o o n o o b r e I y w t i r ‘l e d S o c m ou y t b l- o a s w t ; t o b d h 0 e m lp y o d th .t e ty r t p o e o G p o le d a a n t d a l r l r l y im c e o e u ; nlry $e ls made ot lhe namec, ddreca€s, and other confldential inlormaton, to koop myseil phnin ly stono, martally awake, and mordly sbalgil. Ihe 8SA and its atfini$ groups aray use registrathn inlormallon to nolify reglslrants ol beneflt opporUnllles. Scoul taw For o g r e n rl s d r t s l W qtm ,lc tl o on tt e [ , o c g m ,c ta n c t lo y r o u o t l l B ru SA tt lo p c o a lh l l c e o c u . ncll A Sco d u e t d b b n tr t u , s c tu h r e o e rh rf y u . l , l [ o t y ti a & l , h e b l r p a f v u e l, , f d ri e e a n n d , l y a . n c d o t r e n v e a o r u e s n . l . klnd,
BSA ADULT APPLICATION fl fittr mli !c drlcahd h ado. b Foct$ tqr ltglffifdt. Rlltnme{Hl!.edffil fftldb nrmr lrst DtnE S0lfr wctin ‘Thom,s Qa lacc4e_ County Hom!Adfcts t @ hbol BlUl t lni V vd(lryD t y l l tW /q F o-sr, //^ rr- crv Wsfr lp@G $ “ ocf NScnttltfln 4 ttr0tQ r l@ ;,7 All.^ E w ilrnh bqclrgo - u.d: Ow Bldd trh@fli f’ i Carcrtaumre f thuw Anredcar C Hisprtk/Llho C Ahlla ll8dls C,Pddffc blrldot Oman C Otrr Grndec;( r{,,F Ftnuypharc Albrnabfidto Extitiol tffiffi I’ rtcnllo I tlmaadroipurpafsmcoolcornrulcalin C Erufl f Phooicaf (- smVfod ffttqqppaaoonn Bnaildftss l(6.” lo (o4 a (J t na t ! . 4a.,-t fc/, “t / /4J -,. -,s t ^tt ( &ryou il E c6 Scult? Yls {-t ilo^ t t tEo l ,.nL / qrd n eElano{ / LEa l 0llm - tn/’d l d/y’l0ql- Etnpw fcArAnrto C.tD ttf qdor. lr$ !. rwn d, stlb toG lf tlot ryd|o.!L’ 3. MarcsS.ncl! (hrK loFar$. b-. thr’oUwrrbccluro|odhasffiollnn l A ts * tlo 1, ?Sodufnreo b l r dryortd. cot tcf YAi “ - ‘ 1 lq 1- * - V - Z T 7 ^ . l- - T { t - - . z .t - - P c ., t e “ , t 1 “f / ., / I , n - 1 y “ f-i? T l Y dUru’0trrntho,ffi.yioldoosy?Eroldn: Notftr bob ,-tcn.-js - l. Cumant fr$ottlgs0!Ieh!,tdtrfifu.buLrqhbor.or c. Ha! yo$drlrcrb Icffi sylrtoen sapaded a Yob3 xllo Ae6l!,B rofilltr dt| tqfi h fr. dedr.lioll& D’JtF$s-sFb/€ld70:d;;t;h-l’in:P{.” 4-‘F/r 1 f’rrsA rodtod? Etghln: Plose crwdr coolasl hlormtlin lq al hasl two bdm. &trsn ihn SLho h”.t - Cs D d,_’. D,-,J fft”-cnrJ P o C p o h l n t a h o “ d e * t n d g S 1 f 5 1 i lt 6 t a t l i f “ o ^ l S r t . l < J t l 1 f z l ‘ - ‘ z C f j 4 / t - ^ ‘ a^ s 7 oc 7 l 2 1 1 .1 26 - 1 -5 < 3 - ; A a d d l L . b E lid d r i E l o i d d l y h t o i o n h u lr o y f p i o a r d w t u r f o b o ! { . c n r ‘ . s c o h n 0 n n a l i r ‘ n m l c o o f l l a . t d ! f d u i f l t l c x o t e f m r r r r i o c b . r d . a . h : s i ! b r lo i ! x 0 d ? u Q E r a f q , w l la h h r a : 6 f v t a lft d. t o E { r $ f c t a i h l a n } . o : g u 6 d o y w cr { h b a * tn F f tc r f n i$ og le ls d c t E ol , r & m 1r h s o 0 r d d d .l d? Yoer Fllj 0fgrdalbn Cm@ nrmc Pione I hrrDtcr.firm n’llls ,z/toft3 r,lril rdrn.ntutrl.!.rllh ffidndeb! frh4l,l ryr lo.oDltufi TI|ITTED th. lrl.l d rqttfE c h! ls ri h lo.d..lld. Hd|o n s{fif frd. c mrt V4- Z l llm h.l b hffion mllld fi t+?dt ht F hll nd &anb b lr lldld rt VL stdnoartilcrr Drb lslolrtd$Jld LLl S fff onOruurc..fincao.Md Jld H{toird C’lcl,lrdt ittlGlmt!!t.ll.d . TO BECOMPLETED BY UNIT ‘ htow ftridr ol ilB hfmnetiot !/foyklddl [trir SgDhatbr is a sigffwrt CeO h Soor,{frtg5 Gibra b gfrd. i8 yurtt rtr’fibcn sf, ddtw I q4f,ly Fryun. ,t qpflctl,o,tt slpuE D0 s,6rnifid b lns ,Ml cilItttc, wilth 5 Dttsfpss drf’ r h o ffi l s m F a o d R .l, n ltt I f I r l v lI { t p Is hS ‘ na I l ll | t F m r i r P tl d o t b n . b r l # p l t c liI d il t c l l u rr t d lh c 0 r l p c( p r l . t r d ff r i o b w e t V h $ c G t ! r .. r : l ,, f l f h ir c r d td q ‘ t l { t . 1 rd ‘ rn l D r? c B . o $ v .r A t t b F b C a r q d lt # * tfl h 0 d f r . , ts lp t g t a l c c . T nt ll o x @ l’ . S aa : a lh a .r U . . r . o rL a * 4 u d br r r .l 9 lc 5 n .l t o o ,t t d d l mo lE lq i C $ c e E E{ $ t 6 ft [ b if i b t h r q . i d .h lt t nfid !|tt 3b!G!,lrHtl.h n Sf h.ddhh. BSt t/ryl waffiaut/faturlLdrE H u ca d d yrr orclrc.rdsrrddYnt o 0r a Gadlrrdl tnttpra altlbl 0!b EIU$rr Cscqf Erlclftu rdBlglr troo:B’aa< OTroop Oaew Oshlp ll apfl&art has a curenl rsff.tEr ln ilothof urit ff l@l mmcl, t$ .qi!trithn nay b0 O tew toadsr O romer lsadsr O pocltlar ctnnga O artcipant corrdclld et no dlargo by bilsferhd hs ]8Csrctlm r mlfplo rogBlsthg. Unil llo. or Dl3ldrl nam unillb.orDirtrhln m€ Sc0uilngtuel$mCods Sciltrlgtudtidlll[o Trardenhg trun lhil/tDancil: l$-ll$ 1l{l’“0’ o Ca$r O lranstappticati$ O Multlpb applhauon O Pack O Troop O Cror O shlp o lee Check No. Enbr nsmbor8hlp ilmbl’ &dstatonfes, Cdlndl $codt &foe o freditcard from unGxoled .eglsltalho: 94-501
Teor offthefollowing pages and provide to applicant separately BACKGROUND CHECK DISCLOSURE A consunrer report is a background check in which information (which may include, but is not limited to, crimi’ nal backgrour,i, d.iuir,g background, character, general reputation, personal characrcristics, and mode of living) *b,rut you is gathere{ .o**unicated by a consunrer reporting agency (‘CRA”) to Boy Scouts of America and,’” or its subsidieries, affil “ ia r, t , e 1 s , other related entities, and/or successors (the “Company”). The Company may obtaln a consumer report on you to be used for employment purposes (in your case, this means for the purpose of evaluaring )tou as a new or existing volunteer)’
CALIFORNIA STATE I-AW DISCLOSURES (Non’Credit) Under California law, an “investigatirre coruiumer reporC’ is a consumer teport in which information on a consumer’s character, general reputation, personal characteristics, or mode of living is obtained through any means. Boy Scouts of America and,/or its suboidiaries, affiliates, other related entities, and,/or successors (the “Company”) may obain an investigative consumer report (which may include information described aborrc) from an investigative con$umer reporting agency (“ICR,,I ) on you in connection with your status as a volunteer (i.e., for employmenr purposes under California law). The neture and scope of this investigation includes lour character, general reputation, personal characteristics, or mode of living information, including criminal history and driving recorld. The ICRA preparing the investigative consumer repott and conducting the investigation will be First Ad.,antage, P.O. Box 1A5797, Atlanta, GA 30348, 80O845600’f. Information regarding First Advantage’s privacy practices can be found at https:.//fadv.com,/priracy’policy/. Under California Civil Code secrion 1786,27,you are entitled to a visual inspection of files maintained on you by an ICRA, as follows, (1) In person, if you appear in person and furnish proper identification, during normal business hours or, reasonable notice. A copy of your file shall also be available tb you for a fee not to exceed the “nd actual costs of duplication services prodded; (2) BV ccrtified mail, if you make a wrinen reque$t, with proper identification, for copies to be sent to a specified addressee. An ICRA complying with requests for certified mailingp under California Civil mail after such mailingp learrc the ICRA; (3) A summary of all information contained in your files and required to be provided by the California Civil Code section 1?86.10 shall be provided to you by telephone, if you have made a written requesr, with proper identification for telephone disclosure, and the toll charges, if any, for the telephdne call are prepaid by you or charged direcdy to you. “Proper ldentification’ as used aborre, mearur infotmation generally deemed sufficient to identifr you, which includes documents such as a valid driver’s license, social security number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or farnily history in order to verify your identity. The ICRA will prwide trained personnel to c:<plain any information furnished to you pursuant to California Civil Code section 1?86.10 end will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be prwided whenever s file is provided to you for visual inspection under California Civil Code section L786.22. You may be accompanied h one other person of your choosing, who must furnish reasonable identification. An ICRA may rcquire you to furnish a written statement granting permission to the ICRA to discuss your ftle in such person’s presence.
Additional Disclosures The suu dlsclacnra bclow atc lacladd bccaasc state low rcquhes thcm lo bc provlded In wdtlng Sonc of the Man’ right, nodccg or lnfotmation also rlay apply b lrultviduclsfrom, app$lng lo, or whrnhcrhg ln sUtcs not llrted bctot* Therc moy be addi$otulrcquircmatt, opfians,orprofisions appltcablcu you andyoa lrlay havc aildilional rlgh6 undcr ryplicrble lcwdularc not rcquirudto bc dllctosedto lou inwltlng. MbISgb; You have the right to request a conrplete and accurate disclosur€ of the nahue and scope of any consumer report from Firsr Advantrgc, P.O. Box 105292, Atlants” GA 30348, 800-845-6004’ New York Boy Scouts ofAmerica and/or ie subsidiaries, affiliates, otber relatcd cntitics, andor successors (the’€ompany’) m8y r€qucst or utilizc subscqucnt consum€r reports (other than investigtive ootuumer r€ports) on you throughout your voluntcer rclationship with thc Company. Upon requesf you will bc informcd whether or not a consumcr report was rcqucsted, and if such r€port was requested informcd of the name and addrcss of the CRA tbd fumishcd thc rcport. Your writtcn rcquest should be mads to Boy Scoub of Amcricq Membcnhip Stmdards Team 5201, 1325 West Walnut Hill Lane, P-O. Box 152079’ In ing,IX 75OlS-201g.You nay also contact the Company by emait at ManbcrshipStanderds@scouting’org AUTHORTZATTqN (Pleasc print) Nanrc: First l(tnr n Middle fAr,n.i ljst C| 1. (e 1 <-* Suffix List any o0rer namcs used (nickname, rnaidcry’manied last names: DateofBirth: ot/r;l /fS,! _ UnitTypc and lfumbcn To thc cxtent permittcd by applicablc law, I hereby con$ot to and authorize the Boy Scouts ofAmerica andor its subsidiaries, afrliatcs, other related entitics, and/or succcssorc (the “Company’) to procure consumer r€port(s) (as defincd by federrl law) and/or invcstigative consumcr rr,port(s) (as defined by epplicablc Califomir statc law), wbich in my ctrsc mcans crirninal background check(s/driving rccord(s), on my background from a consuncr rcporting agcncy (‘CRA’) or from an investigative consurner reporting agency (‘ICRA’), as dcscribcd in the Background Check Dbcloture and the Cgilfornle Strte Lrw Dfucltrrurcs (Non{rcdt$ (cach of which I havc rcccivcd scparately ftom thc Company), as well as thes€ Addtdonel Dlsclorures & Beckground ChcckAuthorlzrtlon. This aulhorization applics only to criminal chcckJdriving rccords and docs not allow the Compeny to obtain crpdit checks. I havc rwiewed and understand the information, statcments, and potices in the Brckground Check Dbclosurc and the Cellfornie Strte Lrw Ilfuclolurer (Non{redlt), as well as thesc Addttlonrl Dlrclocurer & Brckground Check Anthorizafion. My urthorization rcmains valid throughout my voluntccr rclationship with the Company, such tlnt, to the extent permined by applicable law, I agree the Company can Procure additional consumer report(s), which in my case mear$ criminal background check(s/driving record(s), during my volunteer rclationship without providing additionat disclqrures or obtaining additional authorizations. Except as otherwisc pmhibitcd by applicablc law, I consent to agrd authorize tbe Company to shere this information with the Company’s local councils and/or chartercd organizations for business reasons (e.g., to place me in certain positions, work sites, ctc,). I undentand that, if I am selected for a voluntccr position, a consurncr r€port will have beetl conducted on me. ! For Crllfornh, Mlnnecotq or Oklrhoma lndMduels: If you would like to receive from the CRA, the ICRA, or the Company (as applicable) a copy of thc report that thc Company may procurc, please check this box. ?t– {./- Date 1=,/t o /z s Signature
o o ctt (5 (L io E6,E E * $- d c) u8 =” ‘e, g
Original PDF: Pack 1232 Adult Application - Kevin Calacone - Signed.pdf