Meritorious Action Award Form – Fill Out and Use This PDF

A committee of the ________________________________________________Council, No. ________, Region _______________

City ____________________________________________________________ State _______________________ has interviewed

Name __________________________________________________________________ Age at time of action ________________

Parent’s name ________________________________________________________________ Phone number ________________

Address ______________________________________________ City ___________________ State __________ Zip __________

The candidate is registered as a Tiger Cub, Cub Scout, Webelos Scout,

Boy Scout, Varsity Scout, Venturer, or adult (circle one) in ____________________________________________ No. _________

(pack, troop, team, crew, ship)

Chartered organization ______________________________________________________________________________________

of City ____________________________________________________________________ State _________________________

Rank at time of action __________________________ If an adult, indicate present office in Scouting ________________________

Upon consideration of the evidence submitted from all sources, as set forth in this application, we respectfully recommend that the National Court of Honor grant the award checked below. Note: If the action being considered is deserving of merit but does not qualify for a national award, do not submit this form. You may want to write a letter conveying the commendation of the committee. Local Council Certificate of Merit, No. 33732, is suitable for this purpose.

PERSONAL SIGNATURES, COUNCIL COMMITTEE

(At least three signatures are required.)

__________________________________________________________________________________ ______________________________________________________________________________________ __________________________________________________________________________________

(Chairman)

__________________________________________________________________________________ ______________________________________________________________________________________ __________________________________________________________________________________

I certify that the individual recommended for recognition was a registered member of the Boy Scouts of America at the time of the action described herein and that the procedure outlined on the back of this form has been followed.

Attest ____________________________________________	________________________________________________
(Scout executive)	(Date)

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REQUIRED DATA FOR ALL CASES

Name of individual recommended for recognition ____________________________________________________________________

Age at time of action ______________________ Approximate height __________________ Approximate weight _________________

Name of rescued person ______________________________________________________________ Phone ___________________

Address __________________________________________________________ City ____________________ State _____________

Age at time of action ______________________ Approximate height __________________ Approximate weight _________________

Name and location of place where action occurred __________________________________________________________________

_

Date and time of incident: Date __________________________________________ Time __________________________________

Enclosed are the following personally prepared and signed statements which are required for all cases: (Type all handwritten state- ments and staple to originals.)

•Personally prepared and signed statement by person performing action, describing the incident.

•Personally prepared and signed statement by the rescued person, if any.

•Personally prepared and signed statement by each witness, describing the action as he or she recalls the details. Include name, address, and phone number of all witnesses.

•Glossy photo of the individual who made the rescue (5" × 7" desired.)

•Summary by the council committee of the event as described on page 5.

•Letter explaining the delay in submitting this recommendation. (Required only if this recommendation will arrive at the National Court of Honor more than six months after the date of the action. It should be signed by the Scout executive or adviser to the lifesaving and meritorious action committee.)

ARTICLE X—SECTION 5—RULES AND REGULATIONS OF THE BOY SCOUTS OF AMERICA

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For Water Rescue (In addition to data on page 2)

General weather and water condition, including approximate temperature ____________________________________________________________________________________________________

(Storm, high seas, fair, calm, cold, etc.)

Lake, river, or ocean? _____________ Its name? ____________________________________________________________________

Condition of bottom (weedy, snags, rocks, sand, or mud) ______________________________________________________________

Still or running water? ________________ If running, speed of current? __________________________________________________

Were others besides rescuer on the scene when the accident occurred? __________________________________________________

Was rescuer assisted in the rescue? ___________________ If so, by whom? ______________________________________________

Did anyone else attempt the rescue and fail? ________________________________________________________________________

Was rescue made by use of boat, buoy, or other equipment or was it a swimming rescue? ____________________________________

If by swimming, was boat or other equipment at hand which could have been used? ________________________________________

If swimming rescue, how far did rescuer swim in order to reach person assisted?____________________________________________

Depth of water at point where rescue was made ______________________________________________________________________

How far was it necessary to tow person assisted in order to stand up or reach safety? ________________________________________

What clothes was rescuer wearing at the time of the rescue?____________________________________________________________

How was the assisted person clothed? ______________________________ Unconscious when rescued? ______________________

Did assisted person struggle or grasp rescuer while being aided? ________________________________________________________

If so, did it result from bad judgment or careless approach? ____________________________________________________________

Was it necessary to go underwater to find person assisted? __________ How many times? _________ At what depth? ____________

Did assisted person live? ________________________________________________________ If revived, give details of method used.

Was Scout training employed in the rescue and resuscitation? Give details ________________________________________________

Is rescuer regarded as a good, fair, or poor swimmer? ________________________________________________________________

For Ice Rescue (In addition to data on page 2)

Thickness of ice at and near point of rescue ________________________________________________________________________

Depth of water at and near point of rescue __________________________________________________________________________

Manner in which rescuer moved over ice ____________________________________________________________________________

Distance traveled by rescuer (a) from shore to breakthrough ____________________________________________________________

(b)over dangerous ice ________________________________________________________________________________________

Location of ladders, rope, planks, etc., if any, and use made of them______________________________________________________

Did ice break under rescuer? _____________ If so, at what point and in what depth of water? ________________________________

Did rescuer fall in? ______________ If so, how did the rescuer get out? __________________________________________________

Did assisted person live? _____________ If revived, give details of method used____________________________________________

Was Scout training employed in the rescue and resuscitation? Give details ________________________________________________

Is rescuer regarded as good, fair, or poor swimmer? __________________________________________________________________

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For Rescue From Fire (In addition to data on page 2)

Dimensions of the room or rooms involved in the rescue ______________________________________________________________

What was the location of the fire at the time of the rescue? ____________________________________________________________

Where was the rescued person when reached by the rescuer? __________________________________________________________

How far did the rescuer have to go to reach the rescued? ______________________________________________________________

Did the rescued person or persons have to be carried to safety? ________________________________________________________

Did dense smoke impede the rescue? ______________________________________________________________________________

Did the rescuer know the building layout? __________________________________________________________________________

Describe in detail the danger to rescuer at time of rescue. ______________________________________________________________

Did assisted person live? _____________ If revived, give details ________________________________________________________

Was Scout training employed in the rescue and resuscitation? Give details ________________________________________________

For First Aid Cases (In addition to data on page 2)

Was the first aid administered by this currently registered youth or adult member instrumental in saving life? How? ________________

What Scout first aid skills were used? (artificial respiration, control of bleeding, etc.)__________________________________________

Were the circumstances such as to tax his coolheadedness? Explain ____________________________________________________

Was he assisted? If so, by whom and how much? ____________________________________________________________________

Did assisted person live? _____________ If revived, give details ________________________________________________________

Was Scout training employed in the rescue and resuscitation? Give details ________________________________________________

Miscellaneous Cases

In cases that cannot be covered under any of the sections, give as much data and as many details as possible to help the National Court of Honor to evaluate the case, paying particular attention to the use of Scout training.

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SUMMARY OF THE ACTION

(This summary of just what happened in the rescue effort is required. It is a narrative description, prepared and signed by the coun- cil committee, based on its study of all aspects of the case and on interviews with the principals and witnesses.)

(If more space is needed, use additional pages.)

THE ABOVE SUMMARY IS REQUIRED.

SAMPLE SUMMARY

The following sample summary is given to aid your committee in preparing a synopsis of this case:

When on May 14, 1982, William McCandless, 11, slipped on the bank of the Stillwater River behind the Englewood Dam near Englewood, Ohio, the fast current carried him into the main stream and through the tun- nel under the dam. Eagle Scout Mark Sanna, 14, prepared for such an emergency by years of Scout training, removed his shoes, jumped into the 80-foot-deep water, and swam to his aid. Mark got William to shore where he used the mouth-to-mouth method of rescue breathing until the victim responded.

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PROCEDURE

1.It is recommended that the local council advancement committee or the volunteer recognition commit- tee or subcommittee thereof be constituted as a lifesaving and meritorious action awards committee.

2.Unless there are unusual circumstances that account for the time lapse, no application may be consi- dered after a lapse of 6 months from the action without a written explanation from the Scout executive or adviser to the council committee.

3.Separate applications are required if more than one member is being recommended for recognition.

4.The council committee must investigate the case, interview the principals and witnesses, secure neces- sary signed statements, and make a recommendation based upon a full knowledge of the facts. It is recom- mended that this committee meet within 30 days of the receipt of the recommendation.

5.Only members of the committee present during the interviews and involved in the investigation should sign the application. The National Court of Honor reserves the right to contact individual principals or witnesses in the case or members of the investigation committee.

6.The council committee bears the responsibility to:

a.Write a summary of the event

b.Complete the application in detail

c.Provide any attachments, newspaper clippings, etc., which pertain to the case

7.It is recommended that no case be forwarded to the National Court of Honor without the endorsement or statement of an eyewitness.

8.All recognitions are reserved for members who were registered at the time of the action. No such mem- ber should be encouraged to submit an application on his or her own behalf.

9.Caution is urged not to submit weak cases (in terms of meaningful action or documentation) to the National Court of Honor. Deliberations are conducted by the court not only to recognize deserving individuals but also to preserve the historical integrity of the awards.

10.Ensure that all names are spelled correctly. Names, as spelled on this application, will be used to record and inscribe appropriate certificates.

Address all requests for forms and other communication to:

National Court of Honor

BOY SCOUTS OF AMERICA

1325 West Walnut Hill Lane

P.O. Box 152079

Irving, TX 75015-2079

PRINTINGS OF THIS FORM DATED EARLIER THAN 1995 MUST NOT BE USED.

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