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 09/27/00                               

                         Scout Personal Data

 

 

   Name:   _______________, _______________   Nickname: _______________

 

   Home Address:        ______________________________

                        ______________________________

 

   Mailing Address:     ______________________________

    (if different)      ______________________________

 

   E-mail:              ______________________________       

 

   Home Phone:          (___) __________   ________ Phone: (___) __________

 

   Date of Birth:       __/__/__     Date Last Physical  __/__/__

   Joined Pack:         __/__/__     Current Grade:___ Eligible Webelos:__/__/__

   Became Tiger:        __/__/__ Cub:__/__/__ Webelos:__/__/__ BScout:__/__/__

   Badges Earned:Bobcat:  /  /  Wolf:  / /   Bear:  /  /   Webelos Badge:  /  /.

   BSA#:                __________   Boys Life: Y / N    

   SSN:                 _______________

 

   Medical Alert:       ______________________________

 

   Father:                               Mother:               

   _______________, _______________      _______________, _______________

 

   DOB: __/__/__  SSN:  _______________  DOB: __/__/__  SSN:  _______________

   Drivers Lic/State: _________________  Drivers Lic/State: _________________

 

   Employ: ____________________          Employ: ____________________

   Occup:  ____________________          Occup:  ____________________

   Work Phone:     (___) __________      Work Phone:     (___) __________

   Cell/Pag Phone: (___) __________      Cell/Pag Phone: (___) __________

   Fax:            (___) __________      Fax:            (___) __________

   E-mail:                              E-mail:                            

                                              Insurance:

   Vehicles: (Year, Make, Model)   # Belts    Per Person   Accident Property

     ____  __________  __________  ______     $______      $______  $______ 

     ____  __________  __________  ______     $______      $______  $______ 

 

     Remark 1:  ____________________________________________________________       

     Remark 2:  ____________________________________________________________       

     Remark 3:  ____________________________________________________________       

     Remark 4:  ____________________________________________________________       

 

   Emergency Contact:

   Relation:                             Relation:                                     

   _______________, _______________      _______________, _______________

   Work Phone:     (___) __________      Work Phone:     (___) __________

   Cell/Pag Phone: (___) __________      Cell/Pag Phone: (___) __________

   Fax:            (___) __________      Fax:            (___) __________

   E-mail:                              E-mail: