Register – Troop 65 Hershey

Account Email or Username*

Account Password*

Confirm Password*

For Which Group Are You Registering Your Scout?*

Scouting ID Number

Scout's Date of Birth*

Scout's First Name*

Scout's Last Name*

Scout's Cell Phone Number

Scout's Email Address*

Scout's Street Address*

Scout's City*

Scout's Zip Code*

Primary Parent Contact – First Name*

Primary Parent Contact – Last Name*

Primary Parent Contact – Cell Phone Number*

Primary Parent Contact – Email Address*

Do you give permission for your child's image to appear on the non-membership pages of this site?*

Yes, I give permissionNo, I do not give permission

Home Address Same As Scout*

YesNo

Primary Parent Contact – Street Address

Primary Parent Contact – City

Primary Parent Contact – State

Primary Parent Contact – Zip Code

Additional Parent Contact – First Name

Additional Parent Contact – Last Name

Additional Parent Contact – Cell Phone Number

Additional Parent Contact – Email Address

2nd Can Be Contacted In Case Of Emergency?*

YesNo

Additional Parent Home Address Same As Scout

YesNo

Additional Parent Contact – Street Address

Additional Parent Contact – City

Additional Parent Contact – State

Additional Parent Contact – Zip Code

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