Istrouma Area Council, Boy Scouts of America
2017 National Scout Jamboree
Boy Scout, Venturing Application and Contract
First Name
Initial
Male Female
(Check One)
Last Name
Address --- street or R.F.D.
Additional Address Information (If Needed)
City
State
Zip Code
-
BSA Member ID Number
Date of Birth
Jamboree Age (As of 07/19/17)
12
Month
Day
13
14
15
16
17
18
19
20
Year
(Check One)
Primary Email Contact Address (Print)
Area Code and Telephone Number (Cell)
IAC Unit Number
Area Code and Telephone Number (Home / Other)
-
Registering as Scout/Venturer (Print One)
-
-
Current Rank (Check One)
Tenderfoot
Star
Second Class
Life
First Class
Eagle
Scout/Webelos
Venturer
Unit Leader's Name (First and Last)
Application Agreement
With the enclosed, non-refundable application fee of $250.00, I apply to be a member of the Istrouma Area Council’s (IAC) 2017 National Scout
Jamboree (NSJ) contingent. I understand that to be considered I must have registered online with the NSJ. In addition, my parent/guardian must have
completed the online NSJ Parental Consent, which includes the Summit Waiver. Further, I understand that in addition to completing and signing this
document along with my parent and delivering it to the IAC Scout Office, I must provide the IAC Applicant’s Record page included in this document to
my scouting unit leader, who must complete, sign, and return it directly to the IAC Jamboree Committee at the Scout Office. I understand that I must
have been active in a troop, team, or crew for at least six months prior to July 1, 2017, and that I must be approved by my unit leader and local council
(IAC) and be accepted by the jamboree leader. If accepted, I agree to live by the Scout Oath and Law and to obey and cooperate with my jamboree
leaders, to meet my full responsibilities as a member of the IAC jamboree contingent, follow guidelines and policy established by the IAC Jamboree
Committee, take such preliminary jamboree training that will be required, and to wear only the complete Field (Class A) and Activity (Class B) official
jamboree uniforms (shirt, shorts, belt, hat, socks, council jamboree insignia) at pre-jamboree events, while on tour, and at the jamboree. I agree that
prior to the jamboree trip I will have a current, government issued picture identification card, and agree to complete and submit to my IAC jamboree
leader by the time requested the official jamboree health form signed by a licensed health-care practitioner as evidence of fitness to make this trip; I
also agree that I will obtain required immunizations and meet NSJ BMI requirements. I further agree to sign the agreement/registration forms required
by the travel company or others. While every effort will be made to place me in the jamboree troop of my choice, I understand and accept that it may be
necessary to place/relocate me in a different IAC jamboree troop.
If a Boy Scout, I certify that I am or will be at least 12 years of age by the first day of the jamboree (July 19, 2017) or an 11 year old that has
graduated the 6th grade, but will not reach my 18th birthday by the last day of the jamboree (July 28, 2017), and understand and agree that I will be
at least a First Class Scout by July 1, 2017. If a Venturer, I certify that I am or will have graduated the 8th grade or be at least 14 years of age by the
first day of the jamboree, but will have not reached my 21st birthday by the last day of the jamboree.
2017 National Scout Jamboree
Statement of Understand, Code of Conduct, and Terms & Condition Waiver
STATEMENT OF UNDERSTANDING:
All participants (youth and leaders) are selected by their local council to represent their local councils based on their qualifications in character,
camping skills, physical and personal fitness, and leadership qualities. Therefore, all adult and youth participants and their parents or guardians are
asked to read the Code of Conduct and Statement of Understanding as a condition of participation. It is with the further understanding that serious
misconduct or infraction of rules and regulations may result in expulsion, at the participant’s own expense, from the Jamboree or during the
Jamboree tour. Each participant is responsible for his or her own behavior, and only when necessary will the procedure be invoked to send a
participant home from the Jamboree.
IAC 2017 National Scout Jamboree Youth Application and Contract
Page 1 of 5
December, 2015
CODE OF CONDUCT:
1. The units’ adult leaders are responsible for the supervision of its membership in respect to maintaining discipline, security, and the
Jamboree Code of Conduct.
2. Leaders will be guided by the Scout Oath and Scout Law and will obey all U.S., local and state laws.
3. Participants will set a good example by being neatly dressed and presentable. (The official BSA uniform and/or Jamboree identifying
items are the only acceptable apparel as deemed appropriate for the activity.)
4. Participants will attend all scheduled programs and participate as required in cooperation with other unit members and leaders.
5. In consideration of other unit participants, participants agree to follow the bedtime and sleep schedule of the unit, unless otherwise
directed by the Jamboree program.
6. Participants will be responsible for keeping their tent and personal gear clean and neat. All personal gear will be labeled with appropriate
name and unit information. Participants will adhere to all Jamboree recycling policies and regulations. All participants will do their best to
prevent littering of the Jamboree grounds.
7. Participants understand that the purchase, possession, or consumption of alcoholic beverages or illegal drugs is prohibited on
BSA/Summit property.
8. Serious and or repetitive behavior violations including cheating, stealing, dishonesty, swearing, fighting, and cursing may result in
expulsion from the Jamboree or serious disciplinary action and loss of privileges. The Jamboree headquarters must be contacted for the
expulsion procedure to be invoked. There are no exceptions.
9. Participants understand that gambling of any for is prohibited.
10. Participants understand that possession of lasers of any type, and possession or detonation of fireworks is prohibited unless otherwise
specifically authorized by the Boys Scouts of America.
11. Participants will demonstrate respect for unit, Jamboree, and Summit property and be personally responsible for any loss, breakage, or
vandalism of property as a result of their actions.
12. Neither the unit leaders nor the Boy Scouts of America will be responsible for loss, breakage, or theft of personal items. Theft will be
grounds for expulsion.
13. Participants will obey the safety rules and instructions of all supervisors and staff members.
14. In accordance with U.S., local, and state laws, firearms and weapons are prohibited in the possession of all Jamboree participants unless
otherwise specifically authorized by the Boy Scouts of America.
15. All leaders must complete Youth Protection training prior to the pre-Jamboree training and follow the guidelines therein.
16. Hazing has no place in Scouting; nor do running the gauntlet, belt lines, or similar physical punishment.
17. Patch and souvenir trading should occur only between your peers except when otherwise permitted.
18. Participants and staff members may only bring items specified on the equipment list provided by the Jamboree Department and National
Council.
19. Violation of this Code of Conduct, or any conduct deemed to be inconsistent with the values of Scouting, may result in expulsion from the
Jamboree at the participant’s own expense; and could result in revocation of BSA membership.
20. All participants (with the exception of minor children accompanied by a parent or guardian) will have a current photo ID in their
possession.
TERMS & CONDITIONS WAIVER:
I (we) approve and agree to all the terms and conditions of this application and certify that the applicant meets the health and physical fitness
requirements of the Jamboree.
This application includes my request for personal accident insurance to be purchased on my behalf. This policy is excess to any other
available source of medical benefits. The cost of this insurance is included in the Jamboree fee. It is understood that payment of claims by the
insurance company is contingent upon prompt reporting of claims, in any, by the participant.
I understand that the Jamboree will be covered by news, media, moviemaking, and broadcasting companies, and I hereby consent to the use
of my voice and/or photograph in the news coverage, moviemaking, or similar projects approved by the Boy Scouts of America without
compensation and I further agree to release and hold the Boy Scouts of America harmless for any and all claims and liability with regard to
such use.
In consideration of the benefits to be derived from the participation in the 2017 National Scout Jamboree, any and all claims against the Boy
Scouts of America or its local council, the United States of America, state of West Virginia, or any of the officers, employees, agents, or other
representatives of any of them, or any other persons working under their direction or engaged in the conduct of their affairs, arising out of any
accident, illness, injury, damage, or loss or harm to or incurred or suffered by the applicant named above or to his property, in connection with
or incidental to the 2017 National Scout Jamboree, including preliminary training and travel, are hereby expressly waived by the parents and
the applicant.
IAC 2017 National Scout Jamboree Youth Application and Contract
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December, 2015
Istrouma Area Council (IAC) Jamboree Payment Agreement
The cost of the IAC 2017 National Scout Jamboree program is $1,825.00. The cost includes the jamboree fee,
travel, meals, lodging, unit equipment, accident and sickness insurance, and IAC pre-jamboree training. The cost
listed here does not include the cost of two required uniforms, personal clothing, personal gear, and any personal
spending money for the scout, all of which will be the responsibility of the scout.
Payment Schedule:
The payment schedule listed below will be followed for all youth participants. Payments should be made and
received at the IAC Scout Office on or before the scheduled due date.
Notes: All payments should be made by mail or in person at the IAC Scout Office.
When a scout makes application after January 30, 2016, it is the responsibility of the scout and
parents to propose a payment plan satisfactory to the Istrouma Area Council whereby all
previously due payments will have been made up by January 30, 2017.
Application Fee (Non-Refundable)
Monthly Payments
Due Date Due
$250.00 At Time of Application
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
Due
January 30, 2016
February 28, 2016
March 30, 2016
April 30, 2016
May 30, 2016
June 30, 2016
July 30, 2016
August 30, 2016
Total Due (Contracted Amount)
$100.00
$100.00
$100.00
$100.00
$100.00
$100.00
$175.00
Due Date
September 30, 2016
October 30, 2016
November 30, 2016
December 30, 2016
January 30, 2017
February 28, 2017
March 30, 2017
$1,825.00
Because of the strict National Scout Jamboree and vendor progress payment requirements and significant late fees,
scout must adhere to payment schedule. The Total Due (contracted amount) of $1,825 must be paid in full by
March 30, 2017. No participant will be allowed to make the trip until the total contracted amount is paid in full.
Failure to make payment in full or failure to make payments on or before the dates due may result in participant
being removed from the active jamboree roster and being replaced by an alternate scout. Such removal will be
considered a drop and subject to the refund policy as defined below.
Refund Policy:
1. Authorized refunds will be made to applicants upon receipt of written notice of cancellation, subject to terms
of Refund Policy. Written notice of cancellation must be received at the Istrouma Area Council office.
2. No refund will be made for the initial $250.00 registration fee, regardless of circumstances.
3. Per National Scout Jamboree Refund Policy, if signed up to attend the jamboree and then find you cannot
attend, a refund will be processed only if your local council has a replacement contingent member.
4. No refunds will be made for equipment and services contracted by the Istrouma Area Council on behalf of
the applicant, unless and until an alternate is secured and approved and payments are current to fee
payment schedule.
5. There will be no refund or rebate following the jamboree.
6. If a scout is placed as an alternate on a waiting list, but no vacancy becomes available, the scout will
receive a full refund of what has been paid.
IAC 2017 National Scout Jamboree Youth Application and Contract
Page 3 of 5
December, 2015
Signatures of Acceptance
Along with and on behalf of my child and myself, I (we) hereby approve and agree to all the terms and conditions of
this application and certify that the applicant can meet the qualifications and the health and physical fitness
requirements of the jamboree and will be examined by a licensed health-care practitioner. I (we) have read and
agree to the provisions in the Code of Conduct, Statement of Understanding, and the Terms & Conditions Waiver
as a condition of participation in the 2017 National Scout Jamboree.
I (we) hereby give my permission and agree for my scout to attend and participate in IAC pre-jamboree training,
jamboree troop events, IAC jamboree junior leader training (if required), and to travel to and from the 2017 National
Scout Jamboree including tour travel.
I (we) do hereby agree and accept the IAC jamboree payment terms and conditions.
Applicant Scout’s Signature (Also Print Name)
Date
Parent(s), Guardian(s), or Adult(s) Serving in Place of Parent(s) (Also Print Name)
Date
Parent(s), Guardian(s), or Adult(s) Serving in Place of Parent(s) (Also Print Name)
Date
IAC 2017 National Scout Jamboree Youth Application and Contract
Page 4 of 5
December, 2015
Applicant’s Record
Part A of this Applicant’s Record must be completed by the scout and then provided to scout’s unit leader.
Unit leader must complete and sign Part B of Applicant’s Record and then deliver to the Scout Office in order
for the Application and Contract to be considered. Failure to do so will result in no consideration being given.
Part A - To Be Completed By Parent(s) Or Guardian(s)
Scout’s Full Name: ________________________________________________________ Date of Birth: _____________________
Scout’s BSA Member ID Number: ____________________________________________ Telephone: ______________________
Special Accommodation Required (Dietary, Other): ___Yes ___No
School Attended: __________________________________________________________ Last Grade Completed: _____________
School Achievements: ________________________________________________________________________________________
Extracurricular Activities: ______________________________________________________________________________________
Community Participation, Including Religious Life: __________________________________________________________________
________________________________________________________________________________________________________
Part B - To Be Completed By Unit Scoutmaster/Advisor
Leader’s Name: __________________________________
Scouting Information
NOTE: After completing Applicant’s Record, leader should
return this form to Scout Office in a sealed envelope
marked- “Applicant’s Record for (youth’s name)To be opened by IAC Jamboree Committee only.”
Number of Years in Scouting: ___Cubs ___Scouts ___Other
Active in Unit: ___Yes ___No
Camping Experience:
Council Camp(s) (Name/Year): ___________________________________________________________________________
High Adventure Base(s) (Year): __________________________________________________________________________
Previous Jamboree(s) (Year): ____________________________________________________________________________
NYLT Training (Year): __________________________________________________________________________________
Leadership Positions Held (Check All That Apply): ___ Patrol Leader
___ Team Captain
___ President
___ Senior Patrol Leader
___ Assistant Patrol Leader
___ Team Co-Captain
___ Vice President
___ Assistant Senior Patrol Leader
___ Quartermaster
___ Leadership Corps
___ Secretary
___ Scribe or Historian
___ Program Manager
___ Squad/Crew Leader
___ Treasurer
Guide for the use of the Council Jamboree Selection Committee, to be completed by unit leader.
Check Appropriate Column:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Excellent
Good
Average
Poor
Unknown
Yes
Yes, With Reservations
Scouting Record
Extracurricular Activities
School Record
Community Participation, Including Religious Life
Personal Appearance (Correct Uniform and Insignia)
Speaking Ability
Scouting Ideals
Attitude
Leadership Experience
Camping and Outdoor Experience
I fully recommend this youth to participate in the IAC’s 2017 National Scout Jamboree program.
No
(***Leader to Check One Box***)
Leader’s Certification: _______________________________________________________________________________________
(Application will not be accepted without unit leader’s signature)
Signature and Printed Name
Position and Unit
Date
Leader’s Contact Telephone Number(s): ________________________________________________________________________
[The following will be completed by the IAC Office]
Council Approval: ___ Participant
___ Alternate _______________________________________________________________
Signature Council Jamboree Committee
IAC 2017 National Scout Jamboree Youth Application and Contract
Page 5 of 5
Date
December, 2015