Scout Personal Data Collection Form

Name:________________________________          Nickname:________________
BSA ID# _____________

Address:                           Mailing:
_________________    __________________
_________________    __________________
_________________    __________________

Phone(s) Home:(___)_________  DOB:__/__/__
               Office:(___)__________ Grade: _______
                   Cell:  (___)_________ School:___________
                 Email: ___________________________

Joined Unit: __/__/__ Cub Scout: __/__/__ - __/__/__
                                           Highest Cub Badge __________
Boys Life: Y/N             Health Form on file: Y/N

Emergency Contact:___________  Phone: (___)_________
Physical Class:  1__/__/__ 2 __/__/__ 3__/__/__
Doctor:______________ (___)__________
Insurance:______________ Policy#: ______________
Allergies:__________________________________________
Other:____________________________________________

Prior Experience:
From             To               Level       Unit:        Council:
__/__/__   __/__/__   ______  ______   ______
__/__/__   __/__/__   ______  ______   ______
__/__/__   __/__/__   ______  ______   ______

Father:______________  Mother:________________
 Nickname: ___________   Nickname: ______________
 Guardian: Y/N                    Guardian: Y/N
 Phones:
 Work: (___)_________    Work: (___)__________
 Home:(___)_________     Home: (___)__________
 Cell:   (___)_________     Cell:     (___)__________
 Email:______________    Email:________________
Drivers Lic#:                        Drivers Lic#
__________ St:_____        ___________ St:_____
Employer: ____________ Employer: _____________
Occupation:___________ Occupation:____________

Insurance (in thousands):
Vehicle    (year/make/model) # Belts  Lic Plate Per Person   Per Accident  Property
_______________________      _____     ______    _________    __________  _______
_______________________      _____     ______    _________    __________  _______

Remarks:_______________________________________

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