Reference Check

Adult Scout Leaders

Please read this form, fill in the information requested and sign in the space provided.

I, ________________________________, hereby authorize [fill in chartering organization name

here] to contact the references listed below to evaluate whether I am qualified to lead youth in
Scouting activities. I also understand that the results of these checks will be held in strict
confidence and only used for the above stated purpose.
Full Name: ___________________________________________________
Date of Birth: __________________________________

Signature: ______________________________________

Date: _________________

Reference 1:
Name: _____________________________________________________________________
Address: ______________________________________________________________________
Email address: ___________________________________________
Reference 2:
Name: _____________________________________________________________________
Address: ______________________________________________________________________
Email address: ___________________________________________
Reference 3:
Name: _____________________________________________________________________
Address: ______________________________________________________________________
Email address: ___________________________________________