I I I ArtmpLlcArroil t #ilre$ffiT ihis applicalirrrr ls also availafile in Spanish. Esta sclicitud tambien estf disponible en espafrol. h{ls$lf}N The rn;r,r;ion of the BSA is to preparo yoilng people to make ethical and rnoral choices over their lifetirnes by instiiling in them the values of the Scout Oath anc, Scout Law. \tr’.rr participation in the BSA can help youth become better citizens. Adult leaders serve as important role models for youth in the BSA and this application aids the chartered organization in selecting qualified adult volunteer leaders. YOUTI.i PROTECTION TRAINING CRIMINAL BACKGROUND CHECK- All aduit applicants are required to take ln order to complete the adult application this training in order to complete the adult process, you will need to review the differ- ;ipplicat-icn ilrocess- Go to my.scouting.org ent disclosures that have been separately to creeite an nccount and take the train- provided to you. The separate authorization illg nnlrne, ‘{rr contact your local council for form must be signed. and returned when cl.sssroorn tr;linlng. lnclude a copy of your you submit your application.
ccrrrpietior’‘r ceEtificate with this application. EXCERPT FROM THE DECLARATION OF RELIGIOUS PRINCIPLE Ihe ApA rnaintains that no member can grow into the best kind of citizen without rec<tgnir.inE an obligation to God and, therefore, recognizes the religious element in the training of the memben but it is absalutely nonsectarian in its attitude toward that rellgious training. lts policy is that the home and organization or group with which the member is cannected shall give definite attention to religious life. Onty Ster:;ctns willing to subscribe fo these precepts from the Declaration of Religious Frinciple and the Bylaws of the 65,4 sha// be entitled to registen It ll adult ie;.:iclers agree to cornply with the Scouter Gode of Conduct. https://vr,rww.scouting.org/health-and-safety/guidelines-policies/ *The three different background check forms must be torn off and each separately given to the applicant. SKl.: d5:5:3 BOY SCOI.JTS OF AMERICA iill{l!lilllliril|il1il, ;l irli-ai1’ :i,). :, I ri
Leader Requirements What ls the BSA Program? f ne llS’A is (ji;[: ir :i) ai r,lno mest the requirements, and leaders are selected The BSA program is outlined in the official publications of the BSA. At;tivities based on indi’lcual merit. Adrili leaoers must possess the nr0ral, educational, that are not in these BSA publications are not a part of the Scouting progratn. and eniotional qualities that the BSA deems necessary for positive leadership Leaders must not all0w youth members or program participants t0 engage in to youth. They nrust aiso: any unauthorized or prohibited activities. . A{lide by ti}e Sr0ut 0ath. Scout Law, and Scouter Code of C0nduct. The Sli;:i:cti,l:jl,l.{]|nfjdctCanbei0Undat@ Training for New Leaders The BSA is committed t0 your success as a volunteer while servingl yorm;r s.’li$iviiiss,i.trsa:sfj_AUtqL00_(ig:oi-elll_dueu. . Si:bscrile t0 tlre precepi$ ofthe Declaration o{ Religious Principle. people. To help you be successlul, there are training materials designed . Resicle v,riiiin the tiSA or a U.S. territory, or be a U.S. citizen residing for Vou. Training resources are available through your local council and at nu$guils.Ors. outsiCs lire rlSA. . Be ili ?;i:s c{ age cr older ior primary leadership p0siti0ns. “ Sr ‘lii : v i e:r,s cl aE’.’0r cide| fOr assisiant leadership positions. What Makes a Trained Leader? . You are considered a trained leader when you have conrpleted leadet posiiictt- a C r c { n l p rE le n ie c r. “ , l t r ‘ i r r il , r t1 ; P 1, r 1 0 a t r e S r l r i €j c c n t| ie ir d a ini l n ,y g g ( o Y i P n T g ) t b 0 e E fo y r . e rc a iu p l p U li l c g a Q tio ru n i a s n p d r o c c r e e s a s t e in d g specifrc training for your position and have current Youth Protectiott trarnir.:. af i:l:::0: :: “ l: jl,’” l’,. ,:is:iosrre informaticn related to the BSA’s background check Youth Protection Begins Wilh YourM jr’:r ‘ r:rrsr,r’r i::Iillste ind sirtn a Background CheckAuthorization form. Child abuse is a serious problem in our society, and unfortunatslv, :t cai- ot;i lit “ .,ili.r, tirtiil,; 1;,:;rtritn–silei:rfic raining alfl!.s!0u1ns..0lg. classroom anywhere, even in Scouting. For that reason, the BSA continues to create ban’iers to abuse beyond what have previously existed in Scouting, trairi:ng rl.i’; aiso I:e avaiiabie through your local council. It is the philosophy of Scouting to welcome all eligible adults, The BSA is committed to providing a safe environment {0r young people. regardless of gender, race, ethnic background, sexual orientation, All adult leaders must complete Youth Protection training as part of the: registration process and renew their training as required. lt is highly or Senr,ef identification, who are willing t0 accept Scouting’s values recommended that parents who participate in Scouting activities complelr; !i,.iij l!.!ci aily other requirements 0f membership. YPT. To learn rnore about the BSA’s Youth Protection resources, g0 t0 w!ryscoutinq.orq^rain APPROVAL BEQUIRED-UII||T ADUTTS . The chartereri {rrillfiiiatiorr r’epresentative is approved by the head of the Mairdatory Reporting chartere:l ri;afi.rati”rir. Ali otner adult leader applications must be accepted AII persons involved in Scouting must immediately report to local aulhilriltes and api:cvec i),i iire nea0 0f the chadered 0rganization 0r the chartered {::.rr:’ ;:i:lroi i. j:’: Jeillati’/a. any good-faith suspicion or beliefthat any child is 0r has been phvsicaliv ‘’, sexually abused: physically 0r emotionally neglected; exposed to iiny tu:,t 0f violence 0r threat; 0r exp0sed to any form 0f sexual explOitatlOn inciucii;rt: S,roui Bx€cut;:,e or designee nnu$t approve any adults who answer “yes” to ir:ty i{it:’fiit - : ! rf .,rirlirii 0l- Ci tSSl,Cit. the possession, manulacture, or distribution 0f child{ern0graphV, oniint: solicitertion, enticemenl, 0r showing of obscene materiil No person nray abdicate this repofiing responsibility to any other person. APPROVAL REQUIREDCOUNCIL and OISTR]CT ADULTS $r0ut exsculive or designee milst accept and appr0ve all council and Additionally, any known 0r suspecled abuse or behavior that might put a distilct aduli-s. youth at risk must also be reported to the local Scout executive 0r the Sc0uts Scout executive or designee nust approve any adults who answer “yes” t0 First Helpli ne (1 -844-SC0UTS1 or 1 -844-726-8871 ) if your Scout executive tr local council cannot be reached. ar)y Additi0nal lrrfcrmation qyesti0n Youth Protection Policies Tlrc erlult leiicrr application process will not be complete until Youth . Two registered adult Ieaders 2l years of age or over are requtred at all Fr’atecri+n ttaining has been completed and a criminal background Scouting activities, jncluding meetings. There must be a registered female check has begn obtained. adult leader over 2 l in every unit serving females. A registered lentale adull Health inlormation. \id snculd iniorm your unit leadership 0f any condition . ieader over 21 mrst be present for any activity involving female yottth. th’li r,0!-ri iiiir:1 y,rrr ilrrlicipatr0n. Before partrcipating rn aclivities with your One-on-one contact between adult leaders and youth membels is li prohibited both inside and Outside of Scouting. r;;,:^.,r’r’r:’iiti:,l,n:riral Hea!thandMedical Record.No.680-001,found rr r’. ,r. lj r.’ | ,r r!’:’1’::; :’ld OtOVide ttt0 yggf Unit leadership. Thesc and other key Youth Protection policies are addressed in Iltc 1t. ;t r’ Scouf iife. jirljislerei adults gel a specral $1 5’rate. For a subscriptr-on to and at -\,vww.scouting.or . a nlaaiir:iiro iirnt lrciprll cnilCrsn gr0w in the Scouting pr0gram, just fill in the To learn about the BSA’s other health and salety policies, please .Sicril I iie,crrirle 0n thc aDpliratirin and pay the subscription price. revierv the online version of the 6uide to Safe Scouting, lhe ScoLtter Code of Conduct, and the SAFE Checklist, which are available at l;llE ANNUAL NATIONAL REGISTI]Ai’!0r{ FEE lS N0NREFUNDABLF. fryww.scoutino.org/h . BSA Privacy Policy Scout oath The l-rSA rrokrols the confidentiality of the nantes and personal information of llose vrho arir afliiiated with the organization. No commercral 0r unauthorized 0n my honor I will do my best to do my duty t0 God and my country and to obey the Scout Law; t0 help other people at all ttnresl I:rc iS ;r]aiiu’ci ihir nariles. addresses, and other confidential information. ‘r1,’ il$i: ;1:;_l is, :rif’nity Urouils ntay use registration information to notify to keep myself physically strong, mentally awake, and morally straigitt. lcqisi|iin:s trt bi,.nefil 0ppcrtilrrities. Scout Law Fc,r general questi0ns, contacl your BSA local council A Scout is trustworthy. loyal, helpful, friendly, coufteous. kinci, flr lish w’ds.scqqEMdIq for current policies, obedient, cheedul, thrifty, brave, clean, attd revererrl
BSA ADULT APPLICATION All fields must be c0mpleted in order t0 process your registration. Frrst name (Full legal name) l\4iddle name Last name Suffix Sharon Suzanne Heckathorne Country Home Address Date oJ Birth (mm/dd/vvvv) I @ r771,1rg81 FsA–] Timber Ln City MState ztp Social Security Number (required)@1 ]t toso_l@ Glenmont Ethnicbackground: a Black/African C Caucasian^Vhite CNativeAmerican CHispanic/Latino OAlaskaNative CPaciticlslander OAsian COther Gender: ( MOF phone phone Prinrary –] Alternate Exlension l L s”"”tl,’fr I Fo1 F61 F5’,5 I I subscription I Please select your preference of communication: ( Email ( Phone Call lo SMS/Text 0ccupation Enrail address sharon safra n@g mai l. com Economic Withholding Senior Analyst Are you an Eagle Scout? Yes C No i- l t f s0, l en , ter d l ate - earn l ed , Eag l le ( - mmid _ d/yyyy) l Employer NYISO A 1 l . l q S u c e o s u t t i i o n n g s ba M c U kg S r T o u b n e d . answered. Write NoNE it not applicable. 3. P CI r T e Y vroLrs residences (for last 1 0 years) STAIE b. ( H o a th v e e r y t o h u a n e v m er in b o e r e t n ra a tt r i r c e s v t i e o d la t f i o o r n s a ) ? cr i E m x i p n la a i l n o : lfefse Y O es O No POS TION COUNOIL YEAR …111^”‘tt 91,.9:t’^. 3112l3rdStADtl Astora Current membershLps (religiOus. c0mmunity, busrness, labor, or c. Has y0ur driver’s license ever been suspended 0r Y O es O No Expeflefce w0rking with y0uth in Other 0rganizat 00s. prof essronal organizations). revoked? Explain: Please provide conlact iniormatron l0r at least two below. oqrntzattor .r r, C Ph o o n n ta e ct narne _ Additional information. (lVark each answer.) o H r a v c e h a y r o g u e d e v w e i r th b e a e b n u s i e n ve 0 s r t n ig e a g te le d c t 1 o 0 f r , a a c m c r u n s o e r d ch o i f l , d? Y C es O No 0fqanizahtn a. Have you ever been removed fron’r 0r asked to leave a Y C es O No Explain: leadership positi0n in an 0rganization due to allegations Contact nanre reqardinq your personal conduct or behavior? Explarn: Phone 0rgan zatior’l Contact name Phone I hereiry certrfy that INITIALS Digrtally signed by Sharon l. I t h h e a v r “o !l e r s e a a d n d a n r d e q a u fl l a r l m r0 r t s h a 0 t f I t a h c e c e B p S t A th a e n d D t e h c e la r O a c tr a 0 l n 0 0 o u l n R c e il l , r g r r 0 rc u s ! dr P n f g ln c t r h p e e S . c I o a u a l r e e r e C l o 0 d e c o 0 m i p C ly 0 n w d r u lh cl. R S EQ S U H IRED ShafOn HeCkathOrne H D e a c te k : a 2 th 0 o 2 r 3 n .1 e 1.16 10:26:41 -05’00’ 11116123
- I aff rnl thal the rnf0rmatror conta ned rn th s a$li0at 0n rs true and accurate 10 the besl ol my SSH Slgralure ol applrcaft Dale kfowledge and be €i. O YPT c0nrplet0n certtcate attach€d and Backgr0und CheckAuth0rization lorm attached TO BE COMPLETED BY UNIT Careful revierv of the information prcvided on this application is a significant step in Scouting’s effotts to protect its youth members and deliver a quality prognm. All applications sh1uld be submitted to the local c\uncil within 5 business days. APPB0VAISF0RUNITAIIIJLTS lhavercvlewedthisapplrcalionandtheresponsesl0anyquestronsanswered’Y€s,”and APPRoVAL Foli C0UNCIL AND DISTBICT ADULTS; I have revrewed thrs appl cation and ha!e made any follow-up rnqurr es ht!. rrde rny fol 0w’up rnqu res f€cessary to be satrsfied that the applrcait possesses the moral ed!cat onal and necessary t0 be salrsfred that tlre app rcant possesses the moral, educat 0nal and emolonal qualitres t0 b€ ar ad!ll r;il] leader in the BSA. Lra1”etorq.,..ar’o Herdo rpesE”talrrru aLU.r rcpre.pllzUvp Dale Siqnature 0f Scout Executive 0r desrqnee Date ffiypr, Q Pack I Troop C) crew O Srrip lf applicant has a current registration in anolher unit 0r local council, the registration may be L) New leader C Former leader C Position change {) Participant completed at no charge by translerring the registration or multjple registering. \z)2- Unrt No. or Drstrict name Ljnit No, or District name (o*r..lr)-ae l\e.wbf FScoutrng- P0-srtion- ColdFe Sc0ut-ing -PosiltionF Title I Transf erring lrom UniVCouncil: PAID: O Cash C Transfer application C Multiple application C Pack O Troop O crew C strip o Check No. Registration fee Council lee Sc1ut Life fee o Enter membership number Credit card from unexprred reqislralion
Tear off’the.fbllowing poges and provide to applicant sepurately. BACKGROUND CHECK DISCLOSURE A consurner relrort is a backgroun.l check in wl-rich information (which may inclucle, but is r-rot limited to, critni- nal backgrount1, clriving lrackgloun.l, charactcr, general replrtation, 1-,ersonal charactcristics, ancl moclc of living) abor.rt you is gatherecl ancl communicatcci by a consumer rcporting agel-rcy (“CRA’) to Boy Scouts of America ancl/ or its sr.rbsirliaries, affiliates, other relatecl entities, ancl,/or success()rs (the “Company”). The C)ornpally may obtain a colrsuurer report ()11 you to L-re usecl for employrrellt pLlrposes (in yclur case, [his means firl the purpose of evaluating you as a new ()r existiug volunteer).
CALIFORNIA STATE LAW DISCLOSURES (Non-Credit) Uncler Califcrrnia law, an “investigirtivc consumer report” is a consumcr rcp()rt ir-r wl-rich infortutrtion on a consumcr’s chnrirctcr, gcncral reputatiorl, personal characteristics, or mocle of livir-rg is obtained tl-rrougl-r any lurcans. Boy Scouts of America ancl/or its subsidiaries, affiliates, other relatecl errtities, arrcl/or succcssors (thc “C)orlpan1,”) may obtain an investigativc consumer report (which may includc ir-rfbrtr-ratiot-t clescribec{ above) from an investi.qativc cr)nsuulcr reporting agcncy (“ICRA”) on you in conr-rection with your status as a voluntcer (i.c., for empkryrncnt pllrposes undcr Califorr-ria Liw). Thc naturc at-rd scctpc of this inestigatittrr inclu.lcs your charactcr, gcncral rcputatior-r, persor-ial characteristics, or mode of living information, includir-rg crirlinal history and drivir-rg record. The ICRA preptrrir-rg tl-rc ir-rvcstigativc consurrer report and cclnducting the investigatiort wili bc Filst Advantagc, P.O. Box 105292, Atlanta, CIA 30348, 800-845-6004. Irrforrnatior-r regarding First A.lvautagc’s privacy practiccs can l’re fcrtrnd at htps,,/fadv.com,/privacy-pcliicy/. Uncler California Civil Cocle section 1786.72, you are entitled to a visual inspection of files maintained on you by an ICRA, as follows’ (1) In pcrsoll, if you irppcar in pcrson ar-rd furnish proper identification,’,luring normal business l’rours and or-r reasonablc noticc. A copy of your file shall also be available to you for a fee not to cxceed the rctual costs of duplication services provided; (2) BV certifiecl mail, if you make a written request, with proper identification, fcrr copies to Lrc sent to a specifieci acl.lressec. An ICRA corlplying with recluests for ccrtifiecl n-railings un.ler-eaiifcrrnia CiviL Coclc scctic>n. 1786.22 shall not be liablc fcrr.lisckrsures to third parties causccl by mishandling of rnail after such mailings lcavc the ICRA; (3) A sllmnlary of all infcrrmation containecl in your files ancl required to be providecl by the California Civil Code section 1786.10 shall be provided to you by telephone, if you have made a writteu request,.,with proper iclentificatior-r for telephone disciosure, ancl the toll charges, if any, for the teleprl’rone call are prepaicl by you or cl-rarged .lirectly to you. “Proper Itlentificatiol-r” as use.l al-ove, lneans infclrmarion generally deemecl sr-rfficient to identify you, whicl-r irrclu.lei clocuments such as a valid clriver’s license, social security number, military iclentification card, ancl credit car.ls. Only if you .cannot identify yourself with such information may the ICRA require aclditional infrrrrlation concerning yor-rr employment ancl personal or farnily history in ctrcler to verify your iclentity. The ICRA i.vill provicle trainecl 1-rersonnel to explhin any information ftrrnisherl to you purstlant to California Cii’il Cocle se*ion 1786.10 ancl will provide a written explanation of any coc{ed information contained in files maintainecl on you. This written eiplanation will be provided whenever a file is proviclecl to yoll for visual insl’rs(:1i1v11 uncler California Civil Code section 1786.22. Yclr-r rnay be accompaniecl by clne other pers()n of your choosing, who must furnish reasonable iclentificatitln. An ICRA rnay require y()Ll to furnish a written statelnent granting perurission to the ICRA tct cliscttss yttr.rr file in sucl-r’person’s presence.
ADDITIONAL DISCLOSURES & BACKGROUND CHECK AUTHORIZATION Additional Disclosures The stute disc’lttsures helox, ure includetl becottsc state kto requires them to be provided in writitrg. Some oJ tlte belon’ ctpplitnble law that are not required to he disclosed to you irt w,ritiug. Minnesota: You havc thc light to rcqucst a courplctc and accuratc disclosLn’c of tl-rc natr.u’c antl scul-lc of any consumcr rc-port fl.orrr First Aclvantasc” P.O. Ilox 105292. Atlanta, GA 303,1U. U00-845-6004. Nelv \brk: Boy Scouts of Aurerica and/or its subsidiaries, affiliates, othel lelated entities. and/or successors (the “Cotnpany”) ntav reclLlest or utilize subsequcnt corlsull’rer reports (other than investigative consur-ner reports) oll you thfoughout your ancl i1’such rcport \,as rccllrcstcd. infblrncd of thc namc and addrcss of thc CRA that lirrnishcd thc lcport. Yottt’rvrittcn rcqucst slrtrLrlcibcnraclctoBoyScoutsolAnrcrica.McnrbcrshipStandaldsTcamS20l. l325WcstWalnutHill Lane,P.O.Box 152079. Irvin-q. TX 75015-1079. You rnay also contact thc Company by eurail at Men.rbclshipStaudalds(zr,scouting.org AUTHORIZATION (l)lease print) Suzanne Na’rc: [,-ir.st Sharon Middlc 141 Heckathorne. Suff ix Safran (maiden name) List any othcr namcs uscd (nicknamc. rnaidcrr/man’iccl last naurcs: Dare of Bir.th: 08/17 /1981 Unit Type and Nulnber: R^”k "-]Z ‘lir thc cxtent pcnnittccl by applicablc larv. I hcrcby conscnt to and authorizc thc Boy Scouts of Amclica and/tlr its subsicliarics. atilliates. other lelated cntitics. ancl/or successols (thc “C-‘ompany”) to procurc consttlttcr lcporl(s) (as clefined by fcdclal lau’) ancl/ur invcstigativc consumcl leport(s) (as clctincd by applicablc Califblnia statc lalv), which itr lny casc mcans invcstigativc consumcl’rcporling agcncy (“lCRA”). as describcd in thc Background Check Disclosure and the Calilbrnia State Larr Disclosures (Non-Credit) (cach of u’hich I havc rcccivcd scpalatcly fl’om thc Cornpany). as rvcll as thcsc Adtlitional Disclosures & Background Check Authorization. This authorization applies only to criminal chccks/driving rccords and docs not allo, the Corupany to obtain credit checks. I havc reviewed atrd undcrstand thc intbrruation. statcnrcnts. and noiiccs in thc Background Check Disclosure ancl thc Califbrnia State l,aw Disclosures (Non-Credit), as r.vcll as thcsc Additional Disclosures & Background Chcck Authorization. My authorization rct.trains valid thloughout nly voltttrtccr rclationship u’ith tl.rc Corupany. such that. to thc cxtcnt pcrmittecl by applicablc larv. I agrcc thc Colnpany call proctlrc lclrtionship rvithout providing additional disclosnlcs or obtaining additional autholizations. Exccpt as othcrwisc pr:ohibited hy applicablc larv. I consent tcl andlauthorizc thc Corrpany to sharc this intblmation r’vith thc Compalty’s local cottncils and/ol chartered organizations tbl btrsiness leasons (e.g., to place me in cet’tain positions. work sites, etc.). I uuderstand that, if I ar.n selected lbl a voluntcer position. a corsr-lnrel report r’vill have been conducte d ou ure. I For California, Nlinnesota, or Oklahoma individuals: llyou rvould like to rcccivc liorn tlre CRA, the ICRA. or thc Conrpany (as applicablc) a colty ol’thc rcport that thc Company nay procurc. plcasc chcck this box. Sharon Heckathorne D gilally srgned by Sharon Heckathorne ll/1612023 Signatlrc Dale: 2023.1 1.16’10:28:1 6 -05’00’ Darc ll.lclL
Original PDF: Pack 1232 Sharon Heckathorne Adult Application.pdf