2011 central illinois powder horn registration form
TRANSCRIPT
8/8/2019 2011 Central Illinois Powder Horn Registration Form
http://slidepdf.com/reader/full/2011-central-illinois-powder-horn-registration-form 1/2
W h a t :
W h a t : W h a t :
W h a t : P o w d e r H o r n h a s b e e n d e s i g n e d t o h e l p g u i d e a d u l t B o y S c o u t a n d V e n t u r i n g C r e w l e a d e r s t o s a f e l y c o n d u c t
o u t d o o r a n d h i g h a d v e n t u r e a c t i v i t i e s o f a F U N a n d c h a l l e n g i n g n a t u r e . I t p r o v i d e s a n i n t r o d u c t i o n t o t h e r e s o u r c e s
n e e d e d t o s u c c e s s f u l l y l e a d t h e y o u t h t h r o u g h a p r o g r a m o f o u t d o o r a d v e n t u r e .
P o w d e r H o r n i s b a s e d u p o n t h e V e n t u r i n g R a n g e r A w a r d r e q u i r e m e n t s , g i v i n g p a r t i c i p a n t s a n e x p o s u r e t o s o m e o u t d
a n d h i g h a d v e n t u r e a c t i v i t i e s a n d i s n o t
n o t n o t
n o t i n t e n d e d t o b e a c e r t i f i c a t i o n e v e n t .
W h o :
W h o : W h o :
W h o : A n y p o s i t i o n e d - t r a i n e d a n d r e g i s t e r e d a d u l t l e a d e r O R
O R O R
O R b e a r e g i s t e r e d V e n t u r i n g o r B o y S c o u t y o u t h ( 1 6 y e a r s
o r o l d e r ) .
W h e n :
W h e n : W h e n :
W h e n : W e e k e n d # 1 : A u g u s t 1 9 t h – 2 1 s t , 2 0 1 1
W e e k e n d # 2 : S e p t e m b e r 9 t h – 1 1 t h , 2 0 1 1
W h e r e :
W h e r e : W h e r e :
W h e r e : W e e k e n d # 1 : E a g l e C r e s t C a m p , W a s h b u r n , I L .
W e e k e n d # 2 : I n g e r s o l l S c o u t R e s e r v a t i o n , L o n d o n M i l l s , I L .
W h y :
W h y : W h y :
W h y : P a r t i c i p a n t s w i l l b e a b l e t o h e l p f i n d t h e r e s o u r c e s n e c e s s a r y t o s u c c e s s f u l l y l e a d t h e i r V e n t u r e r s t h r o u g h a
p r o g r a m o f h i g h a d v e n t u r e a n d t o h e l p t h e m e a r n t h e V e n t u r i n g R a n g e r A w a r d
C o s t :
C o s t : C o s t :
C o s t : $ 2 5 0 p e r p a r t i c i p a n t -
$ 5 0 n o n - r e f u n d a b l e d e p o s i t r e q u i r e d w i t h a p p l i c a t i o n f o r m
$ 5 0 d u e b y J a n u a r y 2 1 s t 2 0 1 1
$ 5 0 d u e b y M a r c h 1 8 t h , 2 0 1 1
$ 5 0 d u e b y M a y 2 0 t h , 2 0 1 1
$ 5 0 d u e b y J u l y 2 2 n d , 2 0 1 1
H o w d o I s i g n u p :
H o w d o I s i g n u p : H o w d o I s i g n u p :
H o w d o I s i g n u p : P a r t i c i p a n t s n e e d t o c o m p l e t e t h e R e g i s t r a t i o n F o r m , s e c u r e t h e i r S c o u t E x e c u t i v e a p p r o v a l , a n d s
t h e f o r m t o t h e W . D . B o y c e C o u n c i l w i t h t h e i r d e p o s i t .
F o r m o r e i n f o r m a t i o n :
F o r m o r e i n f o r m a t i o n : F o r m o r e i n f o r m a t i o n :
F o r m o r e i n f o r m a t i o n :
V i s i t o u r w e b s i t e a t : w w w . c e n t r a l i l p o w d e r h o r n . o r g Send us an e-mail at: [email protected]
C o u r s e D i r e c t o r : L o n n y J o h n s o n C : 3 0 9 - 5 7 3 - 4 5 0 3
8/8/2019 2011 Central Illinois Powder Horn Registration Form
http://slidepdf.com/reader/full/2011-central-illinois-powder-horn-registration-form 2/2
Name:________________________________________ Date of Birth:__________________
BSA Scout Member ID Number:___________________________________________________________
Address:______________________________________________________________________________
City:____________________________________ State:______ Zip Code:__________________
Home Phone:______________________________ Cell Phone:_______________________________
Email:________________________________________________________________________________
Current Primary Scouting Position:____________________________________________________
Additional Scouting Experience:_______________________________________________________
______________________________________________________________________________________
Adult Leader Training Completed:________________ T-Shirt Size:______________
Date
For Youth, any Trainings Completed:___________________________________________________
Council Name:_______________________________________ Council HQ City:_________________
Checks payable to: W.D. Boyce Council
Mail to: 2011 Powder Horn Course
c/o W. D. Boyce Council,
Peoria Scout Service Center
614 NE Madison Avenue
Enclosed is my Peoria, Illinois 61603Non-Refundable deposit $50*
Phone: (309)673-6136
Installment Payment $50 Toll Free: (800)369-5069
Fax: (309) 673-6184
Payment in Full $250
*Applications are accepted on a first come, first reserved basis. A deposit must be received to reser
your space.
Course Participant:
I understand that this course includes outdoor skills and can be physically demanding. A Bo
Scout of America Annual Health and Medical Record (34605)
http://www.scouting.org/filestore/pdf/34605_Letter.pdf will be required for each participan
To participate in some of the individual activities, additional medical or waiver forms may
required.
Participant Signature:____________________________________________ Date: _____________