Wood Badge Registration - Training

Wood Badge
Spring 2015
Participant Registration Form
Please complete this form and submit with a $100 deposit to register for the Spring 2015 Wood Badge course at Pipsico.
The remainder of the fee is due by Saturday March 7, 2015. Space is limited to the first 48 fully-paid registrants. Deliver
or mail to the Tidewater Council Service Center, 1032 Heatherwood Drive, Virginia Beach, VA 23455, ATTN: Wood Badge
Full Name:____________________________________________ I prefer to be called:___________________
Address:_________________________________________________________________________________
City:________________________________________________ State:________
Zip:__________________
Date of Birth: ___________ Email Address: ____________________________________________________
Employer: ____________________________________ Occupation: _________________________________
Home Phone Number: (
)________________________ Cell Phone Number(
Gender (please circle) M F
)______________________
BSA Member Number:__________________________________
Unit:____________ Unit Type:_______________ Council:_______________________________________
District (Please Circle): Albemarle
Princess Anne
Bayside
Three Rivers
Venturing/Sea Scout Div
Other: _________________
Current Registered Position: _______________________________________ Years in position:__________
Training Dates: (You must have completed basic training and outdoor skills training for your registered Scouting position.)
Youth Protection:_____________ Venturing Youth Protection:____________ This is Scouting:_____________
Fast Start:_____________ IOLS: _______________ BALOO: ___________ VLS: ____________
Other: _______________________________
Years In Scouting As Adult:___________
T-Shirt Size (please circle):
As Youth:_________
Small Medium
Highest Youth Rank:_______________
Large XL XXL XXXL
I accept the invitation to attend Tidewater Council’s Wood Badge Spring 2015 course at Pipsico Scout
Reservation on Friday, April 17 to Sunday, April 19, and Saturday, June 6 to Monday, June 8, 2015. I
understand that attendance at all sessions is mandatory and is required for certification. I have completed the
basic training and outdoor skills training for my Scouting position. I am a registered adult Scout leader or a
Venturer 18 or older. I understand that my participation is contingent upon the submission, before the start of
the course, of a physical examination documented on a BSA Annual Health and Medical Record with proof of
health insurance attached.
Participant’s Signature:______________________________________________
Date:_____________
The Course Director, John Donat, will send more information when this registration is processed. Please
contact John with questions [email protected]
Date received: ______
Amount (check one): ___ $100 deposit
___ Full payment $250 (Deadline 3/1/15) ___ Late payment $270.
If paying in 2014, use Account Number 1-2629-218-00 SW= 6565
If paying in 2015, use Account Number 1-6801-218-20 SW=6218F
Please make checks payable to “Tidewater Council, BSA”.
Annual Health and Medical Record Attached? Y / N
___ Remaining payment: $___________
Proof of Health Insurance attached? Y / N
Registration and Training Certified – Approved For Wood Badge by:__________________________________
Council Scout Executive

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