Wood Badge Participant Personal Resource Questionnaire

1.  First Name:  Middle Name:  Last Name:  Title: Choose One Mr Mrs Ms
    I would like to be called:  T-Shirt size: Choose One S M L XL 2XL

2.  Address:City:State:ZIP:

3.  Phone (H): Phone (W): Phone (Cell): FAX:

4.  Occupation:email:

5.  Date of Birth: (mm/dd/yy):District: Choose One North Star Aptakisic Potowatomi OtherUnit No.:Type: Choose One Pack Troop Troop/Team Troop/Crew Team Crew District Council Professional Post

6.  Council name:Council No.:

7.  Years in Scouting; Adult:   Boy:Rank:

8.  Current registered position:(List only your primary position)

8a.  Unit Position, if not Primary:

9. Adult positions held, and how long?

		How Long		How Long
	Scoutmaster:		Cubmaster:
	Assistant Scoutmaster:		Assistant Cubmaster:
	Unit Committee Chairman:		Den Leader:
	Unit Committee Member:		WEBELOS Den Leader:
	Unit Commissioner:		Venturing Advisor:
	Cub Scout Roundtable:		Venturing Committee Member:
	Boy Scout Roundtable:		Other Positions Held:
	A D C:
	District Commissioner

10. Scouting Awards Received:      District Award of Merit:   Silver Beaver:   Eagle:  Adult Religious Award:

    Other:

11. Physical Condition:

12. Camping Experience:

13. Training Experience: When Completed:?

	Y/N	Date	Other Training Experiences	Date
Fast Start:
New Leader Essentials/This Is Scouting:
Leader Specific:
Outdoor:
Youth Protection Training:

14. State why you decided to participate and what you expect to gain from this experience:

15. Religious Preference:

16. First Aid Training; Red Cross Advance:    CPR:    EMT:   Other:

17. Spouse: Emergency Contact 1: Emergency Phone 1:
                                                        Emergency Contact 2: Emergency Phone 2:

Wood Badge Participant PRQ.
Copyright © 2009 Northeast Illinois Council. All rights reserved.
Revised: 07/11/10