AGC of Western Kentucky & Murray State University Institute of Engineering

Merit Badge Preference List

Scout Name: ___________________________ (please print legibly)

Scoutmaster: Daniel Taylor            Asst.Scoutmaster:  Tate Jenkins   (AS) MB Coordinator: Ginny Mills

Phone:731-394-0398                      Phone:731-446-8629                     Phone:731-499-7268

taylor@spraginslaw.com                murryjenkins@gmail.com    gstroop43242@gmail.com

Troop #: 110  Jackson,TN from West TN Area Council #559

Scout T-Shirt Size

T-Shirt Size – X-Large___              Large___    Medium___Small____

Adult LeaderT-Shirt Size (2 shirts per Troop Only)

T-Shirt Size – X-Large___              Large___    Medium___Small____

T-Shirt Size – X-Large___              Large___    Medium___Small____

Select only 3 merit badges from the list of 14 below.Check those 3 as your 1^st Choice, 2^nd Choice or 3^rd Choice according to your interest or need.

Merit Badge                             Choice

1. Architecture                              1^st ____  2^nd ____  3^rd ____

2. Citizen of Nation                       1^st ____       2^nd ____  3^rd ____ 

3. Citizen of World                        1^st ____  2^nd ____  3^rd ____

4. Communications                       1^st ____  2^nd ____  3^rd ____

5. Computers                                1^st ____       2^nd  ____ 3^rd ____

6. Computer Aided Drafting           1^st ____  2^nd ____  3^rd ____

7. Electricity                                 1^st ____  2^nd ____  3^rd ____

8. Engineering                              1^st ____  2^nd ____  3^rd ____

9. Environmental Science              1^st ____  2^nd ____  3^rd ____

10. First Aid                                   1^st ____  2^nd ____  3^rd ____

11. Home Repairs                           1^st ____  2^nd ____  3^rd ____

12. Plumbing                                  1^st ____      2^nd ____  3^rd ____

13. Welding                                    1^st ____  2^nd ____  3^rd ____

14. Woodworking                            1^st____   2^nd ____  3^rd ____

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AGC of Western Kentucky & Murray State UniversityInstitute of Engineering

12^th BOY SCOUT MERIT BADGE DAY

November 7, 2015 – Murray State University

AUTHORIZATION AND CONSENT FORM

NAME:__________________________________________________

In consideration of the educational benefit to be derived from this activity for my son(s)/ward(s), I have full confidence that reasonable precaution will be taken to assure the safety and well-being of my son(s)/ward(s) while participating in Merit Badge Activities sponsored by the AGC of Western Kentucky (AGC) and Murray State University Institute of Engineering.

I hereby agree to his (their) participation in said activities, and waive all claims against the AGC of Western Kentucky,the officers and representatives of the association, Murray State University and merit badge counselors.

I hereby authorize the representatives of AGC and Murray State University conducting the Merit Badge Day activities, as my agent to consent to such medical or dental examination and treatment as deemed necessary as a result of illness or injury which might occur, while my son(s)/ward(s) is participating in said activities.

I further agree to assume responsibility for all expenses incurred as a result of an examination and treatment.

_____________________________                          ________________________

Parent or Guardian                                                                Date

Address (including City, State and Zip Code)

Phone Numbers (Home, Cell and Work): _____________________________________

List any drug or food allergies:______________________________________________

List any medication being taken:____________________________________________

NOTE:  This completed and signed form must be turned in when registering on the day of the activity, November 7, 2015.  Without a consent form, scout will not be able to participate in the event.