Twin Rivers Council, BSA – Merit Badge Counselor Application First Name Last Name: DOB: Address: City: Zip: Email Address: Phone Number(s) at Which a Scout May Contact you to Schedule Counseling: District Affiliation: Please select one district in which you would like to be listed as a Merit Badge Counselor

FORT ORANGE (Albany Cty) MAHIKAN (Columbia & Rensselaer Ctys) SARATOGA (Saratoga Cty) SCHENECTADY(Schenectady Cty) SIR WILLIAM JOHNSON (Fulton, Hamilton, Montgomery Ctys)

WAKPOMINEE (Hamilton, Warren, Washington, So. Essex Cty) ADIRONDACK (Franklin, Clinton, No. Essex Ctys) Unit Affiliation: To qualify as a merit badge counselor you must be at least 18 years old*, proficient in the merit badge subject by vocation or avocation, able to work with Scout-age boys, and be registered as a merit badge counselor with the Boy Scouts of America.

* Minimum age of 21 required to meet the Guide to Safe Scouting standards for the following merit badge subjects: Canoeing, Climbing, First Aid, Lifesaving, Motor boating, Rifle Shooting, Rowing, Shotgun Shooting, Skating, Small Boat Sailing, Scuba, Snow Sports, Swimming, Waterskiing, Whitewater

I request approval as a counselor for the following merit badges. Current policy of the Twin Rivers Council places a limit of 15 merit badges for which an individual may be approved. Proficiency, rather than simply a working knowledge of the Merit Badge Counselor subject must be clearly shown in order to be approved for the Merit Badge subject. When submitting your qualifications as a Merit Badge Counselor please consider the following: Is this subject in line with your job, business, or profession? Do you follow this subject as a hobby, having more than a “working knowledge” of the qualifications to be a merit badge counselor for the merit badge subject(s)? Attach additional pages as needed. Also, Attach copies of applicable certifications, training and any other supporting information. (i.e.. CPR Certification, NRA Certification, ect.) MERIT BADGE SUBJECT EXPERIENCE/QUALIFICATIONS 1. 2. 3. 4. 5. Have you completed?

Youth Protection YES NO This is Scouting YES NO Have you viewed?

The Merit Badge Counselor Orientation Presentation? YES NO If Applicable, have you completed:

Safe Swim Defense? YES NO Safety Afloat? YES NO * All of these presentations may be viewed online at the Twin Rivers Council website at www.twinriverscouncilbsa.org I recognize the responsibilities of a Merit Badge Counselor and, should I be approved, agree to do my best to fulfill the requirements of this position. As a representative of the Twin Rivers Council, BSA I agree to follow the requirements of the Merit Badge, making no deletions or additions, ensuring that the advancement standards are fair and uniform for all scouts. I agree to have a scout and his buddy present at all instructional sessions. I agree to respond to an annual “Merit Badge Counselor Renewal Survey” if I plan to continue as a Merit Badge Counselor. As the applicant, I give my permission for my name, full address, and phone number, to be published in a hard copy document for distribution and use by registered Troop Leaders of the Twin Rivers Council, BSA. By signing, I hereby give my consent and approval and hold harmless the Twin Rivers Council, Boy Scouts of America and the National Council, Boy Scouts of America and the officers, employees, and volunteers thereof.

Additionally, by checking this block I affirm that I DO wish to be listed on the “Merit Badge Counselor List” on the Twin Rivers Council, BSA website, and DO AGREE to have ONLY My name, Phone, and City* Listed (*Full address will not be posted) I also, understand that I can request my name to be removed at any time by contacting the Twin Rivers Council.

Applicant’s Signature: Date: If you are not a currently Registered Adult you MUST submit an Adult Application with position code # 42(Merit Badge Counselor) with this form.

Mail Completed form to: Twin Rivers Council ~253 Washington Ave Ext~ Albany, NY 12205 For Advancement Committee & Council Use Only District Approval By: Title: Date: Entered in Scoutnet: Initial Date: Entered on Website Initial Date: Hard Copy only