Please complete the following information regarding the scout:
Please return this form to James McLaren - phone (901) 524-4947

Scout’s Name:___________________________________________________________________________

Address:_______________________________________________________________________________

Home Phone #:__________________________ Home Fax #: __________________________________

Scout’s email address (Print clearly):_________________________________________________________

School:_________________________________ Current grade:___________ Date of Birth: ___________

Emergency contact other than parent(s): Name:_________________________ Phone #:________________

Please complete the following information regarding the scout’s father:

Name:______________________________________________ Home # if different: __________________

Work #: _______________________ Cell #: ______________________ Fax #: _____________________

Father’s email address: ____________________________________________________________________

Father’s Driver’s license #:_________________________________________________________________

# of seat belts in your car: _____ Make: _______ Model: _______ Year: ______

Do you have automobile liability insurance on the car listed above with coverage limits

that are at least $50,000/$100,000/$50,000? Yes:_____ No: _____

Please complete the following information regarding the scout’s mother:

Mother’s Name:_______________________________________ Home # if different: _________________

Work #: ________________________ Cell #: _____________________ Fax #: _____________________

Mother’s email address: ___________________________________________________________________

Driver’s license #:________________________________________________________________________

# of seat belts in your car: _____ Make: _______ Model: _______ Year: ______

Do you have automobile liability insurance on the car listed above with coverage limits

that are at least $50,000/$100,000/$50,000? Yes:_____ No: _____

Note: The information regarding automobiles must be completed in order for a parent to drive on any scout outing. All occupants must wear seat belts .

 Date form completed: ________________