NORTHERN NEW JERSEY COUNCIL, BSA

25 Ramapo Valley Road
Oakland, New Jersey 07436
201-677-1000
FAX 201-677-1020

MERIT BADGE COUNSELOR APPLICATION

Check here if you are only ADDING or DELETING merit badges. Complete name, address, badges and sign.
NOTE: No Adult Application form is needed for changes in badges.


(Please print or type the information clearly, and complete an adult application form for additional information, even if registered.)

Name __________________________________________________________________________________________

Home Address ____________________________________ Town _____________________ State ____ ZIP ________

Occupation ________________________________ Hobbies ______________________________________________

I request approval as a counselor in the following merit badges (no more: than 10 per council Advancement Committee):
1. _________________________________________________ 6. __________________________________________________
2. _________________________________________________ 7. __________________________________________________
3. _________________________________________________ 8. __________________________________________________
4. _________________________________________________ 9. __________________________________________________
5. ________________________________________________ 10. __________________________________________________

Please attach on a separate sheet sufficient information regarding your professional, academic, personal training and experience, or active hobbies through which you have acquired advanced skills which demonstrate adequate knowledge needed to counsel scouts for the above badges. Also, indicate experience relating to young people (e.g., Sunday school teacher, Little League coach, Assistant Scoutmaster etc.)

I am currently registered as an adult Scouter. If a registered adult Scouter, please indicate your position and unit
(With town), district or council position
I am not currently registered as an adult Scouter. If a registered adult Scouter, please indicate your position and unit
(With town), district or council position
I have not attended youth protection training.
I attended youth protection training on ______________ at _______________________________

By signing below to be a Merit Badge Counselor:
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 Northern New Jersey Council, BSA. I will teach and counsel scouts as suggested in Merit Badge Counseling) BSA Publication No.34529,in accordance with the merit badge requirements as shown in the current merit badge pamphlet or Boy Scout Requirements (latest edition), BSA Publication No. 33215B, and the youth protection requirements of the BSA.
I have attached an Adult Application (form no. 28-501N1) as is required of all new merit badge counselors. No fee is required for registration as a merit badge counselor.

Applicant's signature: __________________________________________________________________ Date: _________________

IMPORTANT: Until this form and the Adult Application are reviewed and approved, you are NOT appointed and approved as a Merit Badge
Counselor and must not meet with scouts. (See over) You should attend a brief Merit Badge Counselor orientation when offered.

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FOR Office USE ONLY:

Approved: _____________________________________________ Title: _______________________ Date: _____________________

Entered in membership database on (date) _____________________ by Council Office Notified on (date)

Revised - 7 Sep 00