Eagle Scout Scholarship Information Form

This form, in addition to the Foundation’s Scholarship Application and letters of reference from Scout Leader and a member of applicant’s community, school or church, is required in order to be considered for the Eagle Scout Scholarship. Contact the Foundation at (989)875-4222 or at with questions.

Applicant’s Name:Date of Birth:

Years in Scouting: Cub Scout: Boy Scout: Venturing: Varsity/Sea Scouts: .

Date Passed Eagle Board of Review:NESA Member (circle one): Yes or No .

BSA Unit No.:Fill in—Troop, Team, Crew, Ship or Post:

Chartered Organization Name:

Chartered Organization Address:City/State/Zip:

BSA Local Council Name:

Local Council Address:City/State/Zip:

Dates of Gratiot County Boy Scout Troop Membership (minimum 24 months):

I. BSA Leadership Responsibilities (20 pts, 2 pts/position): Indicate those held by listing length of time served.

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Leadership Position / Months / Leadership Position / Months / Leadership Position / Months
Senior Patrol Leader / Librarian / OA Lodge Chief
Asst. Sr. Patrol Leader / Quartermaster / OA Vice Lodge Chief
Patrol Leader / Instructor / OA Lodge Secretary
Asst. Patrol Leader / Crew/Ship President / Summer Camp Staff
Jr. Asst. Scoutmaster / Crew/Ship Vice President / Summer Camp CIT
Den Chief / Crew/Ship Secretary / Other
Scribe / Varsity Team Captain / Other

II. Merit Badges Earned (Maximum 15 pts.)

Number of Merit Badges Earned (over the 21 badges for Eagle Scout Rank): (1 pt.for every 5 badges earned).

The following merit badges are given special consideration and should not be included in the above total. List the date each badge was earned in the space provided (3 pts. each).

American Heritage: Scouting Heritage Scholarship

III. Order of the Arrow Involvement (Maximum 20 pts.) Check all that apply.

Ordeal Member (5 pts.): Brotherhood Member (10 pts.): Vigil Honor Member (5 pts.): .

IV. Scouting Religious Award Earned (5pts.): Yes or No

V. Significant Scouting Activities (Maximum 10 pts.) List all that apply (attach an additional page if

necessary). (e.g., Long-term Camping, Jamboree, Philmont, Venturing, OA-NOAC, OA Conclaves, OA

Fellowships, Polar Bears, OKPIK, etc.).

VI. Community Activities, Leadership and Recognitions (Maximum 10 pts.) Check all that apply. Exclude

religious, school or scout activities, leadership and recognitions.

CROP Walk / Other
Relay-for-Life / Other
Special Olympics Volunteer / Other
Red Cross Volunteer / Other

VII. Scholastic, School, and Extracurricular Activities, Leadership and Recognitions (Maximum 20 pts.)

List all that apply (attach an additional page if necessary).

IX. Hobbies and Special Interests (No points given, but intended to show the breadth of applicant’s interests

and talents.) List all that apply (attach an additional page if necessary).

The signatures below signify the information provided is complete and accurate.

Eagle Scout Applicant’s Signature:

Parent’s Signature:

Unit Leader’s Signature:

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