B-PSA - BRITISH COLUMBIA

      APPLICATION FOR ADULT MEMBERSHIP

[ ] NEW               [ ] RETURNING

Mr/Mrs____________________________________________________________________________________________

                                                                                                                Family Name                                                                                    Given Names

Address__________________________________         __________________________________________________

City___________________________________   Province_______________       Postal Code____________________

Date of Birth___/___/___/(D/M/Y/)      Place of Birth:_______________________    Citizenship? ________________

Home Phone:_______________      Business Phone:_________________       Email:___________________________

Occupation_________________________________             Employer_______________________________________

Adult Service in Scouting/Guiding:    

APPLICANTS AGREEMENT:

I subscribe to, and will actively pursue, the principles that I must, to the best of my ability, love and serve my God, respect the responsibilities and rights of individuals, and act in accordance with human dignity.

I undertake to be guided by the policies of BPSA - BC and to do my best to further the aim of the movement.  I release The BPSA - British Columbia and its Leaders, Directors and Officers of any responsibility or liability for any injury or damage to person or property whatsoever sustained in connection with its activities.

I have submitted my Police Record Check to the Group.

Applicants Signature_______________________________    Date______________   Group _____________________________

The annual fee of $30 is enclosed:         [   ] Cash      [   ] Cheque      (Cheques made payable to: “BPSA - BC Provincial Council")

On behalf of the Group/Council, I have reviewed the interview and references as recorded on the reverse of this form.  I recommend the acceptance for membership of the named applicant as: (write in the appropriate position)

                                                                                                                          _____________________________________________

Signed on behalf of the Group/Council:___________________________________________________________

AS A PRECAUTIONARY MEASURE ALL VOLUNTEER APPLICANTS MUST PROVIDE THE BPSA - BC 

WITH FOUR CHARACTER REFERENCES

THESE REFERENCES MUST HAVE PERSONALLY KNOWN YOU FOR A MINIMUM OF TWO YEARS. 

NO FAMILY MEMBERS ARE PERMITTED.

PLEASE COMPLETE THE FOLLOWING :

PLEASE REMEMBER, YOU WILL BE RESPONSIBLE

WITH OTHER PEOPLE’S CHILDREN.  THEIR SAFETY AND

WELL-BEING MUST COME FIRST.

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Last modified: June 30, 2004.