Scouts 2012 Volunteer Reg

2012-2013 Scouting Year
APPLICATION FOR MEMBERSHIP AND APPOINTMENT OF VOLUNTEERS
This form is to be filled out by an adult volunteer or the parent/guardian of a youth leader with the role of Activity Leader or Scouter-In-Training at the beginning of each Scouting year. This application will be forwarded to the local council office and a copy will be kept by appropriate personnel (i.e. Section Leader, Commissioner, Committee Chair) for response in the event of a medical emergency. It is the responsibility of the adult volunteer or the parent/guardian of a youth leader to notify/update appropriate personnel of any changes in their medical status or other information contained in this form that may occur throughout the Scouting year. Please note that Scouts Canada is committed to respecting the privacy of our members, their families, and our employees, by adhering to the privacy principles set forth in Schedule 1 of The Personal Information Protection and Electronic Documents Act. Scouts Canada's Personal Information Protection Procedures and Guiding Principles and an explanation of this form may be viewed on Scouts Canada's web site at scouts.ca/ca/privacy-statement.
SCOUT GROUP NAME: SECTION TYPE: Beaver Scouts (5-7) Cub Scouts (8-10) Scouts (11-14) Venturer Scouts (14-17) Rover Scouts (18-26) Group Committee MEMBERSHIP INFORMATION: Salutation: Last Name: First Name: Middle Name: Nickname: Gender: Male Female Date of Birth (mm/dd/yyyy): Mr. Miss Mrs. Other SCOUTSAbout Jr. (5-7) SCOUTSAbout Sr. (8-10) Extreme Adventure (14-17) Schools and Scouting Other: SCOUTING ROLE: Section Leader Assistant Leader Other Youth Leadership Roles Activity Leader (14-15) Scouter-In-Training (16-17) New Member Ms. Returning Member Email*: Daytime Ph. #: Evening Ph. #: Other Ph. #: Faith Affiliation: Primary Language Spoken: Current Employer: Occupation:
Street Address: City: Prov/Terr: Postal Code: Country:
Email*: This email will be used as a user name in myscouts.ca if over 18 years of age Are there any family circumstances, cultural or faith requirements of which the leader should be aware? If yes, please advise leader of details. Yes No EMERGENCY /PARENT/GUARDIAN CONTACT INFORMATION:
Adult volunteers require at least one emergency contact. Use this section to enter parent/guardian information and alternate emergency contact for a youth leader. Email is only for the parent/guardian of a youth leader. Emergency or P/G Contact 1: Last Name: First Name: Daytime Ph. #: Evening Ph. #: Alternate Ph. #: Relationship to member: P/G Email*: Emergency or P/G Contact 2: Last Name: First Name: Daytime Ph. #: Evening Ph. #: Alternate Ph. #: Relationship to member: P/G Email: Emergency Contact 3: Last Name: First Name: Daytime Ph. #: Evening Ph. #: Alternate Ph. #: Relationship to member:
Email*: This email will be used as a user name in myscouts.ca if youth is under 18 years of age
PHOTO RELEASE, FUNDRAISING AND DIRECTORY CONSENT, SCOUTING LIFE MAGAZINE:

These items relate to the Scouts Canada's Privacy Policy, and what can be done with the information you provide. Please review the Privacy Policy at scouts.ca/ca/privacy-statement before making your choices. Throughout the Scouting year, leaders, parents and Scouts Canada employees take photos and video of members participating in Scouting activities. These photos are typically kept in group photo albums and displayed on group web sites. Some are also submitted to local newspapers and to Scouts Canadas Communications Services where they are often used in Scouts Canada publications and promotional materials.
I consent to the use of images of myself as indicated above. I wish to be informed about fundraising and other member benefits not specifically related to your Scouting program. I wish to have my name and email address included in the myscouts Employee/Volunteer Directory. Tick the box if you DO NOT wish to receive Scouting Life Magazine.
Application for Membership and Appointment of Adult Volunteers, March 2012 Page 1 of 2
2012-2013 Scouting Year Applicant's Last Name: Applicant's First Name:
INFORMATION FOR MEDICAL EMERGENCIES:

Physician's Name: Insurance Coverage Held: Yes No Yes No If yes, please provide details below: Physician's Ph. #:
Does the participant have any allergies?
Please advise of any medical conditions, diseases, operations, disorders or problems the member has had or currently has. Provide details below:
Does the participant require special care, medication or diet?
Yes
No
If yes, please provide details below:
Date of last tetanus shot (Month and Year): Swimming Abilities: Non Swimmer Swimmer (Highest Level Achieved):
PERSONAL REFERENCES (NAME AND CONTACT INFORMATION):

This is for new applicants only. If a family member is used as a reference, only include one family member. If we have difficulty contacting your references, we will ask you to provide additional references.
1. 2. 3. INFORMATION UPDATE: Adult Name: (Please Print) Adult Name: (Please Print)
Evening Ph. #: Evening Ph. #: Evening Ph. #:
Other Ph. #: Other Ph. #: Other Ph. #:
Note: applicant must sign the Applicant's Agreement at the bottom of this form. This section is to be signed by the applicant when there are updates during the Scouting year.
Signature: Signature:
Date:
(mm / dd / yyyy)
Date:
(mm / dd / yyyy)
APPLICANT'S AGREEMENT OR CONSENT TO PARTICIPATE:

To be completed by the Applicant if over 18 years of age I will subscribe to and actively promote the Mission and Principles of Scouting. I agree, as part of my membership requirement, to submit to and provide a police records check (including a Vulnerable Sector Check) clean of any criminal convictions. I agree to participate in a Woodbadge Part I within the first year. I will abide by the By-law, Policies and Procedures of Scouts Canada (this can be found at www.scouts.ca). I understand that the membership fee for each Scouter paid to Scouts Canada includes the non-refundable fee for one year of the Scouting Life Magazine. I understand that participation in Scouts Canada is voluntary and there is a degree of risk in some Scouting activities. After carefully consideration the risks involved, I will take reasonable precautions to ensure the safety and well being of participants entrusted to me and my personal safety. To be completed by the Parent/Guardian of an Activity Leader or Scouter-In-Training that is under 18 years of age I understand that participation in Scouts Canada is voluntary, and involves a certain degree of risk when participating in some Scouting activities. After carefully considering the risks involved, and having full confidence that reasonable precautions will be taken to ensure the safety and well-being of my (son/daughter/ward), I grant permission for my child/ward to become a member of Scouts Canada and participate fully in its activities.
X
Signature of Applicant
Appointment Approval of Adult Volunteer: Council / Area or Group Commissioner's Signature
X
Date (mm/dd/yyyy) Signature of Parent/Guardian
Name (Please Print)
Date (mm/dd/yyyy)
Date (mm / dd / yyyy)
Note to Leaders: At the end of the year, please forward your copy of this form to your council office.
Application for Membership and Appointment of Volunteers, March 2012
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2012-2013 Scouting Year

APPLICATION FOR MEMBERSHIP AND APPOINTMENT OF VOLUNTEERS

Street Address: City: Prov/Terr: Postal Code: Country:

PHOTO RELEASE, FUNDRAISING AND DIRECTORY CONSENT, SCOUTING LIFE MAGAZINE:

2012-2013 Scouting Year Applicant's Last Name: Applicant's First Name:

INFORMATION FOR MEDICAL EMERGENCIES:

Does the participant have any allergies?

Does the participant require special care, medication or diet?

If yes, please provide details below:

PERSONAL REFERENCES (NAME AND CONTACT INFORMATION):

Evening Ph. #: Evening Ph. #: Evening Ph. #:

Other Ph. #: Other Ph. #: Other Ph. #:

APPLICANT'S AGREEMENT OR CONSENT TO PARTICIPATE:

Date (mm / dd / yyyy)

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