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Microsoft Word - Mission Impossible Camporee Registration Packet.doc
Skyway District
2012 CAMPOREE
ADVENTURES OF AGENT “001”
OCTOBER 19-21, 2012
CAMP SOULE
A Camporee of Night Missions
Under the Moon and Stars!
ADVENTURES OF AGENT 001
SKYWAY District Camporee Camp Soule
October 19-21, 2012
Dear Scoutmasters and Leaders,
This year's theme for the Skyway Fall Camporee is the “Adventures of Agent 001”. Baden-Powell once said, “In Scouting, a boy is encouraged to educate himself instead of being instructed.” It is in that spirit that we offer this year's fall camporee.
The theme Adventures of Agent “001” is to appeal to the sense of fun, adventure, and imagination so active in Scouts to be conducted in the dark of night with Patrol activities.
The camporee will be held October 19-21, 2012 at Camp Soule in Clearwater. Friday night there will be a leaders’ cracker barrel. Saturday’s activities will start at 9:00 AM with open swim, waterfront activities (canoeing, fishing, etc.), service projects, merit badge class, adult training and troop-led activities. The program will begin at 7:00 PM in the council ring. We will use the entire camp, so come prepared to do some hiking.
During the camporee program Saturday night, Camp Soule will be swarming with "secret agents" (Scouts) doing their best to accomplish several fun, but challenging, "night missions” in the foot steps of “Agent 001”. Patrols will be given secret orders that will direct them to their first night mission (event). They will be directed to a total of 11 night missions (including a late night cracker barrel). After each completed night mission, they will be given sealed orders directing them to their next mission. The 11 night missions include:
--- Qubie Gadget Lab --- Blind Escape --- Covert Key Search --- Laser Wire --
--- Star Trek --- Jaws of Death --- Nanobyte Tank Escape ---
--- Secret Stranger --- Enemy Encampment --- Rescue the Astronaut --- Mystery Mission ---
Events will conclude by 1:30 AM. All Scouts should be in their campsites and quiet by 2:00 AM.
Please read the enclosed materials carefully. On-time cost per participant through September 14 is $10 which includes registration, patch, and Saturday night cracker barrel. Late registration begins September 15 and is
$15 per person. “Adventures of Agent 001” camporee t-shirts will be available on a pre-order basis with only very limited quantities available on-site. See enclosed order form.
See you October 19th !
Michael McBrideCandice Nyarkoh
“Agent 001” - Camporee ChairmanSkyway District Executive
727-525-0187727-391-3800 [email protected]@bsamail.org
Table of Contents
Welcome Letter
2
Tee-Shirt Order Form
10
General Information
3
Vehicle Information Form
11
Schedule of Events
5
Camporee Policies
12
Description of Events
6
Evaluation Form (Scouts)
14
Volunteers Needed
8
Evaluation Form (Scouters)
16
Registration Sheet
9
Registration & Fees
General Information
The cost will be $10 per person through September 14. This includes a patch, camp fees, Jaws of Death Cracker Barrel, etc. Late registration, September 15 or later will be $15. It is imperative to register by September 15th for materials to be ordered in time for the camporee weekend. Registration and Payment to WCFC Council Office.
T-Shirts
T-shirts are optional and will be available for pre-order (see form submit BY Sept 14) with a very limited number available at camp. Shirts are $10 for Youth L & XL and Men’s S, M, L, and XL. Men’s 2XL and 3XL are $12.00.
Deadline for Order: September 15th
Event Sponsorship & Program Volunteers Needed
Troops are asked to volunteer to host one of our camporee programs. Most activities will require 2-4 adults. Other available volunteer adults will be stationed around camp through the evening to direct “lost patrols.” Scoutmasters are
asked to contact Becky McBride at mailto:[email protected]?subject=Skyway District Camporee 2012 to reserve an event. Before the camporee, the volunteers will have an opportunity to meet and practice the events. Volunteers will have the entire day on Saturday to set-up their event. Events should be set-up no later than 4:00 pm and will start promptly at 7:30 pm. Volunteers will need to be in position by the start of the program at 7:00 pm.
Check-in and Arrival
Check-in will take place upon arrival and must be completed by the tour leader or Scoutmaster. No scouts or adults will be permitted to go to the campsite until check-in has occurred. Please provide HEALTH forms and TOUR PLAN at check-in.
Troops will also be required to certify the swim ability of their scouts. Troops are requested to bring 2 sets of the circular
swim ability tags (such as those used at camp) or a letter from the scoutmaster. Tags will be available at check-in if troops do not have them, however it will save time if you have them prepared in advance.
Vehicles in Camp
No vehicles will be permitted in camp except a single vehicle towing a troop trailer. Gear transport will be available in front of the dining hall for those arriving without a troop trailer. Individuals requiring handicapped access are asked to
register their vehicle upon arrival.
Parking
Every vehicle that will park at camp is asked to complete the enclosed Vehicle Information Form in ADVANCE of arrival to camp. Vehicle Information Forms should be displayed on the dash board of every vehicle in camp.
Uniforms
Scouts should be in full field uniforms upon arrival, at the Friday Night Leader’s Meeting, and at the Sunday morning Scout’s Own service and closing ceremony. During events on Saturday, please have Scouts dress in Troop Activity uniform (troop t-shirts or other scouting apparel). “Secret Agent” clothing is encouraged for the Saturday night program.
No toy guns or weapons permitted. Prizes will be awarded for the best dressed secret agent and the best dressed secret
agent themed patrol.
Campsites
All campsites will be shared; therefore we ask that troops kindly keep their tents gathered in one area of the site. You will be advised at check-in as to which other units will be sharing your camp site. Please be courteous to your neighbors and
observe campsite cleanliness and quiet hours. Each troop will be expected to share latrine clean-up through-out the
weekend. Troop leaders are responsible for monitoring functionality of the facilities and notifying camp staff if assistance is needed.
Campfires
We will confirm fire status upon arrival at Camp Soule. If fires are allowed please make sure they are in an established fire ring and kept small, keep to “Leave No Trace” principals!
First Aid
All troops are responsible for minor First Aid for their troop members. A first aid kit will also be available at each event station. Major injuries requiring trained medical attention should be reported immediately to 9-1-1 and camp staff should
be notified immediately so that emergency vehicles can be directed to the victim. Please have proper health forms for
each participant.
Friday Night Campfire
There will be no camp-wide program on Friday night. Campfire programs are highly encouraged in each campsite. Scoutmasters and SPLs are encouraged to coordinate campfire program efforts with the other troops sharing each site.
Camporee Leaders’ Meeting & Cracker Barrel (Friday night)
The camporee leaders’ meeting and cracker barrel will be open to Scoutmasters, Assistant Scoutmasters, Senior Patrol Leaders, and Assistant Senior Patrol Leaders to discuss the weekend and Adventure of Agent “001”s schedule and activities. Please meet at the Dining Hall at 9:00 pm. Please ensure appropriate leadership remains with your youth in camp.
Saturday’s Activities
Saturday’s activities will begin at 9:00 am with a flag ceremony at the Council Ring. Troops may choose from activities including swimming, canoeing, merit badges, service projects, and adult training. Water activities dependent upon number of volunteers and weather conditions. Troops may also opt to conduct their own troop-led activities at their campsite such as scout skills or team building. Please plan accordingly to occupy your Scouts! Dinner and clean-up should be completed no later than 6:00 pm. Patrol Costume Judging will take place beginning at 6:30 in the Council Ring. All patrols need to arrive at the Council Ring by 6:55 pm to ensure the program will start on time.
Merit Badge(s)
Merit badge(s) will be announced at a future date. Sign-up forms will be distributed to troops that register or will be available at the leader’s meeting.
Service Projects
Sign-up will take place at the Leader’s Meeting
Pool & Waterfront Activities
Scoutmasters must pre-test swimmers for ability and must provide two adults with Safe Swim Defense+Safety Afloat or Swimming+Water Rescue training as additional pool and waterfront supervision. BSA Lifeguards will be provided. Anyone without a certified swim evaluation/pre-test will be allowed only in the pool as a non-swimmer.
Patrol “Secret Agent” Themes
Patrols that wish to “get into character” for the evening events can choose to dress as secret agents. Patrols wishing to be judged for awards are asked to arrive at the Council Ring at 6:30 pm. Awards will be given to the best patrol and best
individual secret agent themed costume(s).
Jaws of Death Cracker Barrel (Saturday night)
Saturday night will feature a yummy, late-night, camp-wide cracker barrel. The cracker barrel will take place mid-way through the events at 10:30 pm. Please see the schedule provided at registration.
Scouts’ Own Service
There will be a “Scouts’ Own” chapel service at 11:00 am in the Council Ring. We plan to have the entire service led and coordinated by Chaplain’s Aides. Please have Chaplain’s Aides contact Becky McBride in advance of the camporee to
sign up. You may contact her at mailto:[email protected]?subject=Skyway District Camporee 2012
Chaplain’s Aides will have a “rehearsal” on Saturday after lunch. They will also need to report to the Council Ring no later than 10:30 am on Sunday morning.
Closing Ceremony
A very brief closing awards ceremony will take place Sunday morning immediately following the Scouts’ Own service.
Check-out
As with Webelos Fellowship, a staff member will inspect the troop’s camp site prior to check-out. Troops are asked to take home trash. Evaluation forms (enclosed) are required to be turned in at the Scouts’ Own Service or at check-out.
Patches and troop participation ribbons will be in the check-out packet. Again, only one vehicle is permitted in camp to
pick up a troop trailer.
Event Schedule
***NOTE: SCHEDULE IS TENTATIVE AND SUBJECT TO CHANGE***
Friday
6:00 - 8:00 pmCheck in at Dining Hall – Camp Soule
9:00 pmCampfire programs by campsite
Leaders’ Cracker Barrel – Dining Hall
11:00 pmTaps – Lights out & quiet
Saturday
7:30 amReveille
9:00 amFlag Ceremony – Council Ring
9:15 am – 12:00 noonOpen Swim – Pool
Open Waterfront – Lake Chatauqua Merit Badge Class (TBA) Begins Service Projects begin
Adult Training begins
12:00 NoonLunch & Rest
1:30 pm – 4:30 pmActivities resume
Chaplain’s Aide meeting – Dining Hall
4:00 – 6:30 pmRest & Dinner at your campsites
6:30 pmPatrol & individual secret agent theme costume judging – Council Ring
6:55 pmAll patrols report to Council Ring
7:00 pmRetire the Colors
7:05 pmOpening Ceremony – Council Ring
7:30 pmEvents begin
10:30 pm“Jaws of Death” Cracker Barrel – Dining Hall
11:00 pmEvents Resume
1:30 amEvents conclude
2:00 amTaps – Light out & all quiet
Sunday
10:00 amReveille & Breakfast
11:00 amScouts’ Own Service & Brief Awards Ceremony – Council Ring
11:30 amBreak camp and head home
“Adventures of Agent 001”
Camporee EventsSaturday Night
The Scout Activities consist of 11 stations that patrols rotate though during the course of the night. The patrols move from station to station in an assigned sequence. The activities run from 7:30 pm to 10:30 pm and from 11:00 pm until 1:30 am with a camp-wide “Jaws of Death Cracker Barrel from 10:30 pm until 11:00 pm. Each activity is 25 minutes long with 5 minutes to travel between stations. Youth are expected to move quickly between stations and must check-in and check- out with the adult in charge of the event.
Patrols should be ready to give their patrol yell at any time to show Scout Spirit and win “Bonus Points.”
A preliminary description of the Scout Stations, how they may be scored, and advancement opportunities for each is listed below. Patrols will be judged on completing the objective, patrol involvement, working together, and clean-up as needed.
Summary of “Agent 001” Adventures
1. QUBIE’s GADGET LAB
Reporting into Qubie’s Gadget Lab your patrol will be tasked to create a new agent gadget with provided materials. Your patrol only has a certain amount of time to create this gadget making something useful to help with further adventures.
2. BLIND ESCAPE
The Patrol Leader must direct his blindfolded patrol through an obstacle course. This mission stresses teamwork and communications. The Patrol Leader will be tested on how clearly he can give instructions and how well he can keep his
patrol together coaching them through a situation. His patrol members will be tested on how well they can understand directions, carry out instructions, support each other, and work together as a team.
Your group is entering an area that has been tricked trapped by the infamous enemy agent, the “Gremlin”. Your patrol leader trips a wire that creates an explosion. He is injured and must be carried by the group, but he still has his sight. The rest of the patrol was temporarily blinded by the blast. You have just minutes to escape before the entire area is consumed in fire. The Patrol Leader can see, but must be assisted in walking. He must verbally direct his entire patrol to safety. He can see the obstacles, they can't. He has to describe the obstacle, what they need to do, and coach them through it. Time is limited.
3. COVERT KEY SEARCH
This event is a test of your patrol’s ability to use GPS devices and Compasses with given coordinates from headquarters given to you from the secret outpost, your patrol is to find and eat the Golden Keys needed by the enemy to arm missiles in your quadrant before they can launch their missiles.
4. LASER WIRE
Your Patrol comes to a major obstacle to confiscate the enemy’s box of their evil world secrets. One of your Patrol members trips an alarm timer and your whole Patrol must get to the other side of the obstacle before being captured by the enemy’s agents.
5. STAR TREK
This event will provide a great opportunity to observe the heavens and learn about nature.
As the patrol approaches this event, the Star Gazer will meet them. He’ll lead them into a field where the sky opens up above them filled with millions of stars. He leads them to a large area where they can lay down and stare up at the heavens. The Star Gazer describes what a star is, a galaxy, etc. He points out a few constellations and tells of the stories behind their names.
6. JAWS OF DEATH
This is a late-night cracker barrel snack scheduled midway through the events (10:30 pm – 11:00 pm) for everyone to enjoy. It serves as a midpoint where staff can check everyone's status. First of all, is everyone accounted for? Are there
any injuries? Are the events/missions going smoothly?
7. NANOBYTE TANK ESCAPE
This event combines teamwork and how scouts approach a problem. The Patrol finds themselves in a tank they must escape from before the enemy releases Scout eating Nanobytes. With access to 3 special moveable platforms, Patrol members must escape the Nanobyte tank to a safe area 20 feet away. Timing is critical as is the Patrol working together in a team to save the Patrol.
8. SECRET STRANGER
The evil agent is known as the Jobbie. The good agent is known as the Cobol. The Patrol will meet both of them one at a time. They must decide which agent is Cobol and present their top secret CD to him/her. They must determine who is who by asking them questions and judging their character by the responses.
You must get information to a secret intelligence unit of the United States government. Your contact is an agent known only as the Cobol. You have no information about his/her appearance, nor do you have a code word for identification. The original code word was compromised by enemy agents. It is known that an enemy agent known only as the Jobbie is operating in the area and may try to impersonate Cobol to intercept the information on your CD. If your information gets into the wrong hands it could be disastrous for the free world.
9. ENEMY ENCAMPMENT
This event combines some exciting elements, a test of the boys' observation skills, their ability to work together as a team, and their natural desire to run around in the dark desperately trying not to be caught by adults.
The Patrols arriving at this event are met by Bond. He leads, assembles them and explains their mission. An anti- government organization has set up camp and is believed to be training some rather unsavory individuals in domestic terrorism. Right now most of them are gone on a training mission. There’re only a few of them guarding the camp. The mission is to get close enough, under the cover of darkness, to gather intelligence information about the group's camp.
How many tents do they have? How many people are guarding the camp? Are they male or female? How many vehicles do they have? What are the license plate numbers? They can't know you're there. If they see you, it will compromise our entire operation.
10. RESCUE THE ASTRONAUT
This is a quick search & rescue event. The situation is that during re-entry of the secret reconnaissance vehicle the “Alpha-1”, our astronaut “Agent double oh four (004)” had to bail out and your patrol needs to find Agent 004 who has knowledge of covert scout operations that are currently underway. The patrol must act as a search & rescue team to find Agent 004 and treat him for injuries if necessary. Your Patrol must find Agent 004 before the enemy does !
11. MYSTERY MISSION
This is a TOP SECRET mission that will be revealed upon arrival to the event.
Volunteers Needed
Event Hosts – (Adults) Usually one troop per event
Need 2-6 adults per event depending on activity – some events require a bit of minor acting and role playing making it really FUN and MYSTERIOUS for our Scouts. Event overview will be provided – some require props or “costumes.” A
pre-camporee rehearsal is planned.
Campfire Builders (Youth with Adult Supervision)
Saturday Night - a special campfire is planned – troop is needed to help carry out the planned theme. Experience is a plus here!
Chaplain – (Adult)
Advisor for youth planning program – includes bringing resources, and bringing miscellaneous props or other
Chaplain's Aides (Youth)
Need Chaplain’s Aides to help in planning and presenting the non-denominational church service Sunday morning. There will be a meeting after lunch on Saturday and participants must be at the Council Ring by 10:30 am Sunday.
Flag Ceremony (Youth)
Need two teams (for Saturday morning & evening) of scouts in full field uniform to raise and lower the flag.
Bugler/Trumpeter (Youth)
Need a bugler to sound taps, reveille and mustering calls.
May be called upon to provide fanfare sounds at campfire and flag ceremonies.
BSA Lifeguards (Youth age 15 or older or Adults with current certification)
To lifeguard at pool and waterfront morning and afternoon – need 4 – 8 lifeguards
Pool & waterfront supervision – (Adults only, with Safe Swim Defense & Safety Afloat or Swiming+Water Rescue or Paddlecraft Safety training)
Need 16 adults. Daytime duty morning or afternoon.
Cook & Assistants (Adults only)
To prepare staff food, Friday night leaders meeting cracker barrel and Saturday night “Jaws of Death” camp-wide cracker barrel
Service Project Supervisors (Adult)
Will coordinate youth performing service projects under the direction of the Camp Ranger. A truck or SUV with trailer hitch may be needed and helpful
Night Watchmen – (Adults)
Adults not otherwise assigned to a Saturday night event are asked to serve as “Night Watchmen” to direct “lost scouts”
around camp and be the “eyes” of staff. (Duty is from 7:00 pm until 2:00 am) Adults can bring chairs.
VOLUNTEERS ARE ASKED TO CONTACT Becky McBride at [email protected]
REGISTRATON FORM
Troop Scoutmaster _________________ Phone Number __________________
Senior Patrol Leader Number of Patrols
SCOUTS
PATROL NAME:
PATROL NAME:
PATROL NAME:
1.
9.
17.
2.
10.
18.
3.
11.
19.
4.
12.
20.
5.
13.
21.
6.
14.
22.
7.
15.
23.
8.
16.
24.
ADULTS
1.
4.
7.
2.
5.
8.
3.
6.
9.
TOTAL PARTICIPANTS
On-time Registration (through 9/14) x $10 = $
Late Registration (9/15 or later___________x $15 = $ _____________ TOTAL PAID $ _______
**** SUBMIT THIS FORM TO WEST CENTRAL FLORIDA COUNCIL WITH ****PAYMENT ****
T-Shirt Order Form
To ensure your t- shirt – please pre-order shirts NO LATER THAN “SEPT 14”
*** NOTE: Very limited quantities may be available on-site but are not guaranteed.
Make Copies of this form as needed, identify Scout Name, Size, Quantity, Price/Total.
Submit T-Shirt Pre-Orders to WCFC prior to September 14th.
Shirt sizes
Youth L & XL - $10.00
Men’s S, M, L, XL - $10.00
Men’s 2XL and 3XL - $12.00
#
NAME
SIZE
QUANTITY
PRICE
TOTAL
TOTAL ENCLOSED
$
**** SUBMIT THIS FORM TO WEST CENTRAL FLORIDA COUNCIL WITH ****PAYMENT ****
VEHICLE INFORMATION FORM
Please display on dash of vehicle at arrival to camp
NAME:
TROOP NUMBER:
CELL PHONE NUMBER (in camp contact):
HOME/OTHER CONTACT PHONE NUMBER (in case of emergency):
SKYWAY DISTRICT CAMPOREE OCT 19th – OCT 21st
Camporee Policies
The following rules were made to help us have a successful and safe camping experience. It is the responsibility of the adult in charge to see that their Scouts know and understand these rules. Anyone caught violating these rules maybe asked to leave camp.
VehiclesSpeed limit is 5 mph.
No passengers in the back of an open truck or trailer. Only vehicles with passes are allowed beyond the parking area.
Vehicle towing trailer must be removed to parking lot. Only handicapped individual’s vehicles are allowed in campsites with
appropriate documentation and camp vehicle pass.
FiresIf allowed at the time of the camporee, campfires are allowed only in designated fire rings.
NO FIRES MAY BE LEFT UNATTENDED - CAMP RULE. NO FIRES OUTSIDE OF FIRE RINGS
All liquid fuels and propane must be used under adult supervision.
FirearmsFirearms, explosives, and fireworks are prohibited.
ConservationPlease conserve our natural resources.
No digging, trenching, or raking is allowed.
ABSOLUTELY no cutting of brush or standing timber is allowed. Usually there is an abundance of pre-cut firewood.
Pool &
WaterfrontScoutmasters must pre-identify the swimming ability of all youth and adults using the pool and waterfront facilities. Unit classification form attached for you to in.
Troops are asked to bring circular buddy tags for each pool or waterfront participant.
Buddy system will be STRICTLY OBSERVED!
Swimmers may use all facilities. Beginners and Non-Swimmers may NOT use
Pool &
Waterfront
waterfront canoes and boats, but may fish.
Fishing is permitted with catch & release only.
Bring your own fishing pole and tackle.
Access to pool and waterfront is only permitted during posted times. Violation of this rule will result in youth being sent home.
Adults in CampA responsible adult (age 21 or older) must be in camp at all times. You are responsible for your Scouts.
CamouflageCamouflage pants, shirts, and jackets and/or toy weaponry are not allowed.
*** Toy guns or weapons will NOT be permitted for the patrol and individual secret agent themed costume and will DISQUALIFY them from judging.
Knives
NO straight bladed knives are allowed.
First AidFirst Aid will be handled in campsite or at the First Aid Station.
LIGHTS OUTScouts are not allowed out of their site after lights out except to
and from the latrine.
ALL QUIET PLEASE
Scouters are asked to bring roaming Scouts to the staff headquarters.
ElectronicsNo MP3 players, iPods, cell phones, TVs, DVD players, radios, stereos, CD players, headsets, etc. are allowed.
PropertyAny person caught stealing or causing damage to automobiles, Camp Soule property, or troop property will be turned over to the proper authorities. REMEMBER WE ARE SCOUTS.
Skyway District
2012 Camporee Evaluation
Unit #
Please have the SPL and ASPL complete
1).What did you like best about this Camporee and why?
2).What did you like the least and why?
3).What things do you think could have been done differently to improve this Camporee?
4).Which event did you like the best and why?
5).Which event did you like the least and why?
6).How was the location of the Sunday morning Vespers service, and recognitions?
7).What would you like to do next time for events?
(Turn Over)
8).Overall, on a scale of 1 to 10 (1 low and 10 super), how was this
Camporee?
9).Did you like the Camp Soule? Where else could we have a
Camporee?
Please rate the events from 1 to 10 with 1 being the lowest (never do that again) and 10 being the best (Everyone learned a lot and had a great time). Remember, we are here to learn as well as have a great time. (Jaws of Death does not count)
Rate
Name
Comments
Qubie’s Gadget Lab
Blind Escape
Covert Key Search
Laser Wire
Star Trek
Nanobyte Tank Escape
Secret Stranger
Enemy Encampment
Rescue the Astronaut
Mystery Mission
Thank you - Please turn this in Sunday morning at the
Scouts’ Own Service
REGISTRATON FORM (Extra Copy)
Troop Scoutmaster _________________ Phone Number __________________
Senior Patrol Leader Number of Patrols
SCOUTS
PATROL NAME:
PATROL NAME:
PATROL NAME:
1.
9.
17.
2.
10.
18.
3.
11.
19.
4.
12.
20.
5.
13.
21.
6.
14.
22.
7.
15.
23.
8.
16.
24.
ADULTS
1.
4.
7.
2.
5.
8.
3.
6.
9.
TOTAL PARTICIPANTS
On-time Registration (through 9/14) x $10 = $
Late Registration (9/15 or later___________x $15 = $ _____________ TOTAL PAID $ _______
**** SUBMIT THIS FORM TO WEST CENTRAL FLORIDA COUNCIL WITH ****PAYMENT ****
UNIT SWIM CLASSIFICATION RECORD
Please complete and present this form to the camporee registration desk at your Friday night troop check-in. This is the individual’s swim classification as of the date indicated below. ** Ensure Scouts have two Swim Tags. This signed form signifies the person below signing off on these Scouts have properly tested these scouts for their swimming classification.
Special Note: The designated camporee aquatics director is authorized to downgrade a classification for any scout or group of scouts when he or she is reasonably concerned that pre-camp swim tests were not properly administered.
Unit Number: ____________________
Date of Swim Test: __________________
Full Name (please print)
Swim Classification
Non-swimmer
Beginner
Swimmer
To be completed by person administering the tests.
Print Name: _____________________________________________ Signature:___________________________________
____________________________________________________________________________________________________ Address
City, State, Zip Phone Number
Qualifications: _______________________________________________________________________________________
Unit Leader: ________________________________________Signature:________________________________________