09/05/01                                
                         Scout Personal Data
 
 
   Name:                _______________, _______________   Nickname: _______________
 
   Home Address:        ______________________________
                        ______________________________
 
   Mailing Address:     ______________________________
    (if different)      ______________________________
 
   E-mail:              ______________________________        
 
   Home Phone:          (___) __________   ________ Phone: (___) __________
 
   Current Grade: ___  Cub Scout: __/__/__ - __/__/__ Highest Badge: __________
   Joined Unit:   __/__/__  BSA#  __________          Boys Life: Y / N      
   Date of Birth: __/__/__  Date Last Physical: __/__/__  Class: ____      
   SSN:    _______________
 
   Medical Alert: ______________________________
 
 
   Dates of Prior Service:  __/__/__ to __/__/__  Unit _____
   Dates of Prior Service:  __/__/__ to __/__/__  Unit _____
   Dates of Prior Service:  __/__/__ to __/__/__  Unit _____
   Dates of Prior Service:  __/__/__ to __/__/__  Unit _____
 
   Father:                               Mother:                
   _______________, _______________      _______________, _______________
 
   DOB: __/__/__  SSN:  _______________  DOB: __/__/__  SSN:  _______________
   Drivers Lic/State: _________________  Drivers Lic/State: _________________
 
   Employ: ____________________          Employ: ____________________
   Occup:  ____________________          Occup:  ____________________
   Work Phone:     (___) __________      Work Phone:     (___) __________
   ________ Phone: (___) __________      ________ Phone: (___) __________
   ________ Phone: (___) __________      ________ Phone: (___) __________
 
                                              Insurance:
   Vehicles: (Year, Make, Model)   # Belts    Per Person   Accident Property
     ____  __________  __________  ______     $______      $______  $______  
     ____  __________  __________  ______     $______      $______  $______  
 
     Rmk #1:    ___________________________________________________________         
     Rmk #2:    ___________________________________________________________         
     Rmk #3:    ___________________________________________________________         
     Rmk #4:    ___________________________________________________________