Ktemaque Lodge # 15

OA Adult Nomination Form ________ (Date)

Name

Address

City

State

Zip

Occupation

Special Skills

Phone H(____)____________

B(____)____________

C(____)____________

Email address

Date of birth _____/_____/_____

is registered with

_

(Troop#, Community or District or Council)

BSA Registration number (REQUIRED): ____________

Primary Scouting position

Nominee has camped out

#

days and nights long term (6 consecutive days)

#

days and nights short term (no more than 4 nights) in the last 2 years under the auspices and standards of the Boy Scouts of America

(List of camping dates and places must be included in the Letter of Recommendation.)

No. of boys elected from unit

_____

Date of Election

I have spoken to the nominee and he has agreed to help in the following areas:

OA Service/Induction Weekends............

_____

Promote Camping..........................

_____

Serve as an OA Advisor...................

_____

Help at Service weekends.................

_____

I certify that the Nominee is a currently registered Scouter and has served as a positive role model for the growth and development of youth members of the Boy Scouts of America. I also certify that the information listed on this form is true and correct.

_____________________

______________________

Unit Leader

Committee Chairman

Special Instructions:

1. Adults are 21 years and older.
2. A letter of recommendation to the Lodge Selection Committee must accompany this form. The letter must answer the following questions:

• This adult will be an asset to the Order due to demonstrated skills and abilities, which fulfill the purpose of the Order because:
• This adult leader's membership will provide a positive roll model for the growth and development of the youth members of the Lodge because:
• Selection of the adult is based upon ability to perform the requisite functions (and NOT as an honor or recognition of service) including current or prior achievement and position. The individual's abilities include:
• Please list camping dates and places within the past two years.

3. Mail both the form and the letter of recommendation to:

Ktemaque Lodge # 15
Adult Nomination
41 Saw Mill River Rd
Hawthorne, NY 10532-1519

All information requested must be supplied.
Adult nominations received after April 1st will not be considered.