Scout Personal Data Collection Form                                   
 
 
Name:     ________________________________________          Nickname: ___________________ 
Sex:      M / F               
 
Address:  ______________________________     Mailing:  ______________________________     
          ______________________________               ______________________________     
          ______________________________               ______________________________     
 
Phone(s) Home: (___) __________               DOB:         __/__/__  SSN: ___________ 
_____________: (___) __________               Grade:       _____               
_____________: (___) __________               School:      _____________________________ 
Email:         ______________________________                    
 
Joined Unit: __/__/__ Cub Scout __/__/__ - __/__/__  Highest Cub Badge: _______________ Boys Life: Y /  
 
Health form on file: Y /  
Emergency Contact:   _________________   Phone:  (___) __________ Class 1 Phys:  __/__/__ 
Doctor:              _________________   Phone:  (___) __________ Class 2 Phys:  __/__/__ 
Insurance:           _________________   Policy: ____________     Class 3 Phys:  __/__/__ 
Allergies:           ____________________________________________________________         
Other:               ____________________________________________________________         
 
 
Prior Experience:   From      To        Level     Unit #    Council # 
 
                    __/__/__  __/__/__  ________  ________  ________  
                    __/__/__  __/__/__  ________  ________  ________  
                    __/__/__  __/__/__  ________  ________  ________  
                    __/__/__  __/__/__  ________  ________  ________  
 
 
 
Father:        _____________________________ Mother:        _____________________________ 
Guardian:      Y / N                         Guardian:      Y / N                         
 
Phone(s) Work: _______________               Phone(s) Work: _______________               
____________:  _______________               ____________:  _______________               
____________:  _______________               ____________:  _______________               
Email:         _________________________     Email:         _____________________________ 
 
 
SSN:         _______________                 SSN:         _______________                 
Drivers Lic: _______________    ST: ___      Drivers Lic: _______________    ST: ___      
Employer:    ______________________________  Employer:    ______________________________  
Occupation:  ______________________________  Occupation:  ______________________________  
 
                                                         Insurance (in thousands)      
Vehicle(s)   (Year/Make/Model  # Belts   Lic Plate   Per Person  Per Accident Property 
  ____________________           ____    __________  __________   __________  _________ 
  ____________________           ____    __________  __________   __________  _________ 
 
 
Remarks: ____________________________________________________________