application form

1. S.C.O.P.E. 2017
May 18th
- May 22nd
, 2017
Individual Application
PLEASE PRINT CLEARLY
Section Number and Name (i.e. 1st
Brampton): _______________ ______________
Last Name: First Name: __________________________
Date of Birth: / / Sex: Are you a Scout/Venturer or Leader: ____
YYYY MM DD M/F S/V/L
Address: _______________________________________________________
Apt#, Street#, Street Name
City: _____________________________ Province: Postal Code: ___________
Telephone: ( )- - ______
Scouts Canada Membership Number _ (To Be Completed By Leader)
School Attended: Grade: _____
Religious Preference: ________________________________________________
Canadian Passport Number/Canadian Birth Certificate Number/Landed Immigrant
Number and Status (Circle one and provide information clearly below):
Email Address: ___ ________
(I may receive SCOPE emails – Yes / No)
Special Dietary Needs/ Allergies? _________________________________________________
Pet Allergies? _______________________ Smoke Allergy? ______________
Known Medical Conditions: ______________________________________________________
I give permission for my child/ward to participate in SCOPE 2017 in PA, USA and enclose the
deposit of $100.00 which I understand is non-refundable unless a substitute is found. The balance
is due to the Section leader by January 31st
2017. I understand that it is my responsibility to ensure
that my child/ward has the correct border crossing documentation, as well as proof of out of country
medical insurance.
I have given permission on the Scouts Canada Photography Release Form through my
child/ward’s Section YES ___ NO ___ (Check One)
Signed: Date: _______________________________