Eagle Scout 512 728_WB_Fillable 728 WB Fillable
User Manual: Eagle-Scout-512-728_WB_Fillable
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EAGLE SCOUT RANK APPLICATION FOR COUNCIL USE ONLY TO THE EAGLE SCOUT RANK APPLICANT. This application is to be submitted after you have completed all requirements for the Eagle Scout rank. Print in ink or type all information. List the month, day, and year for all dates. When using computer date blocks, list the date: July 8, 2016, as 07 (for July) 08 (for day) 16 (for year). When you have completed this application, sign it and submit it to your unit leader. Street address or P. O. box ________________________________________________________ City, state, zip ________________________________________________________ Telephone (Including area code) Email ________________________________________________________ Troop, team, crew, ship, or Lone Scout Unit No. ________________________________________________________ Unit city, state, zip TYPE OF UNIT REGION UNIT NO. C, N, S, W PID NO. (REQUIRED) FULL LEGAL NAME (Use abbreviations if necessary; must fit within 30 characters, including spaces and punctuation.) ________________________________________________________ COUNCIL NO. POSTHUMOUS: Month Day Date became a Boy Scout Date became a Varsity Scout Date became a Venturer Date became a Sea Scout Date of First Class Scout board of review Date of Star Scout board of review Were you a Cub Scout? Were you a Webelos Scout? Did you earn the Arrow of Light Award? Had you completed fifth grade upon joining? Year ■ Yes ■ No ■ Yes ■ No ■ Yes ■ No ■ Yes ■ No AGE REQUIREMENT ELIGIBILITY. Merit badges, badges of rank, and Eagle Palms may only be earned by a registered Boy Scout, Varsity Scout, Venturer, or Sea Scout. He may earn these awards until his 18th birthday. Any Venturer or Sea Scout who achieved the First Class rank as a Boy Scout in a troop or Varsity Scout in a team may continue working for the Star, Life, and Eagle Scout ranks and Eagle Palms while registered as a Venturer or Sea Scout up to his 18th birthday. Scouts, Venturers, and Sea Scouts who have completed all requirements prior to their 18th birthday may be reviewed within three months after that date with no explanation. Refer to the Guide to Advancement, No. 33088, section 8.0.3.1, for boards of review to be held between three and six months, or more than six months after the 18th birthday. A Scout, Venturer, or Sea Scout with a disability may work toward rank advancement after he is 18 years of age if he meets the criteria for registration beyond the age of eligibility. See the Guide to Advancement, section 10.0.0.0, for details. Date of birth Date of Life Scout board of review REQUIREMENT 1. Be active in your troop, team, crew, or ship for a period of at least six months after you have achieved the rank of Life Scout. Month Day Year Month Day Year REQUIREMENT 2. Demonstrate that you live by the principles of the Scout Oath and Scout Law in your daily life. List the names of individuals who know you personally and would be willing to provide a recommendation on your behalf. Name Address Telephone Email Parents/guardians _______________________ _______________________________ __________ ___________________________ Religious _______________________ _______________________________ __________ ___________________________ Educational _______________________ _______________________________ __________ ___________________________ Employer (if any) _______________________ _______________________________ __________ ___________________________ Two other references _______________________ _______________________________ __________ ___________________________ _______________________ _______________________________ __________ ___________________________ REQUIREMENT 3. Earn a total of 21 merit badges (required badges are listed). List the month, day, and year the merit badge was earned and the unit number it was earned in. MERIT BADGE 1 CAMPING 2 CITIZENSHIP IN THE COMMUNITY 3 CITIZENSHIP IN THE NATION 4 CITIZENSHIP IN THE WORLD 5 COMMUNICATION 6 COOKING *7 EMERGENCY PREPAREDNESS OR LIFESAVING DATE EARNED UNIT NO. MERIT BADGE *8 ENVIRONMENTAL SCIENCE OR SUSTAINABILITY 9 FIRST AID *10 SWIMMING OR HIKING OR CYCLING 11 PERSONAL MANAGEMENT 12 PERSONAL FITNESS DATE EARNED UNIT NO. MERIT BADGE 15 16 17 18 19 13 FAMILY LIFE 20 14 21 *Cross out badges not earned. If a crossed-out badge in #7, #8, and #10 was earned, it may be reentered in 14 through 21. You must attach the Application for Alternative Eagle Scout Rank Merit Badges for those merit badges earned in place of the Eagle required badge(s). DATE EARNED UNIT NO. REQUIREMENT 4. While a Life Scout, serve actively in your unit for a period of six months in one or more of the following positions of responsibility. List only those positions served after Life board of review date. Boy Scout troop. Patrol leader, assistant senior patrol leader, senior patrol leader, troop guide, Order of the Arrow troop representative, den chief, scribe, librarian, historian, quartermaster, junior assistant Scoutmaster, chaplain aide, instructor, Webmaster, outdoor ethics guide Venturing crew. President, vice president, secretary, historian, den chief, treasurer, guide, quartermaster, chaplain aide, outdoor ethics guide Sea Scout ship. Boatswain, boatswain’s mate, purser, yeoman, storekeeper, crew leader, media specialist, specialist, den chief, chaplain aide Lone Scout: Leadership responsibility in his school, religious organization, club, or elsewhere in his community Varsity Scout team. Captain, cocaptain, program manager, squad leader, team secretary, Order of the Arrow team representative, librarian, historian, quartermaster, chaplain aide, instructor, den chief, Webmaster, outdoor ethics guide Date of Life Scout board of review Position__________________________________________________________________ FROM Position__________________________________________________________________ FROM Month Day Year Month Day Year TO TO Month Day Year Month Day Year Month Day Year REQUIREMENT 5. While a Life Scout, plan, develop, and give leadership to others in a service project helpful to any religious institution, any school, or your community. (The project must benefit an organization other than Boy Scouting.) A project proposal must be approved by the organization benefiting from the effort, your unit leader and unit committee, and the council or district before you start. You must use the Eagle Scout Service Project Workbook, No. 512-927, in meeting this requirement. Project name: _____________________________________________________________ Date project finished Grand total of hours: __________ (from Eagle Scout Service Project Workbook—for statistical purposes only) REQUIREMENT 6. While a Life Scout, participate in a unit leader conference. Date conference was held Month Day Year Month Day Year CERTIFICATION BY APPLICANT. On my honor as a Boy Scout, Varsity Scout, Venturer, or Sea Scout, all statements on this application are true and correct. All requirements, with the exception of my board of review, were completed prior to my 18th birthday.* In preparation for your board of review, prepare and attach to your Eagle Scout Rank Application a statement of your ambitions and life purpose and a listing of positions held in your religious institution, school, camp, community, or other organizations, during which you demonstrated leadership skills. Include honors and awards received during this service. Signature of applicant________________________________________________ Telephone__________________ Date *Or the date established by an extension of time granted by the National Council (see the Guide to Advancement, section 9.0.4.0.). The completion date does not apply to Scouts registered beyond the age of eligibility as provided for in the Guide to Advancement, section 10.0.0.0. Month Day Year Month Day Year Month Day Year UNIT APPROVAL (personal signatures required) __________________________________________ Telephone__________________ Date Signature of unit committee chair_____________________________________________ Telephone__________________ Date Signature of unit leader Scoutmaster, Coach, Advisor, or Skipper BSA LOCAL COUNCIL VERIFICATION. According to the records of this council, the applicant is a registered member of this unit and this application is approved as accurate. Signed__________________________________________ Position_________________________________ Date Month Day Year Month Day Year REQUIREMENT 7. Successfully complete an Eagle Scout board of review. The applicant appeared before the Eagle Scout board of review on this date, and this application was approved. ______________________________________________ Signature of Eagle Scout board of review chair Date ______________________________________________ Signature of council/district board representative (if applicable) I certify that all procedures, as outlined in the Guide to Advancement, have been followed. I approve this application. Scout executive ____________________________________________________________________________________ Date Month Day Year Presentation of the rank may not be made until the Eagle Scout credentials are received by the BSA local council. NATIONAL EAGLE SCOUT ASSOCIATION. As an Eagle Scout, you may now join the National Eagle Scout Association, a fellowship of the top achievers of the Boy Scouts of America. Each Eagle Scout who applies for membership within six months of his board of review receives a $15 discount off the regular five-year membership fee. Join TODAY at www.NESA.org. NESA membership fees go toward the production of the award-winning quarterly Eagle's Call, networking opportunities for Eagle Scouts, and support of NESA’s many programs such as providing college scholarships. Lifetime NESA members are eligible to purchase the NESA life member square knot at their local Scout shops. It is the same as the Eagle Scout knot, but with a silver border, and it replaces the Eagle square knot on the uniform. Please use the most current application found at www.scouting.org/media/forms.aspx. 512-728 April 2017 Printing SUPPLEMENTAL EAGLE SCOUT INFORMATION FORM The purpose of this form is to help the BSA stay in contact with you. The information you provide will strengthen the National Eagle Scout Association as it assists Eagle Scouts in networking with one another. It will also help in determining strategies to increase the number of Scouts who achieve the Eagle rank. Upon conclusion of the survey, you will be dircted to a website where you can download a unique Scouting song (not available anywhere else)! Thank you in advance for your time and input. CLICK HERE TO BEGIN Completing this form is optional. Your privacy will be protected. Information collected will be kept confidential within the Boy Scouts of America and its local councils.
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