OLIVE FORM
Third-Party Witness Statement Indentifying
Scoutmaster, Volunteer or Other Person Connection to Scouting
If Need Help Call 215-515-5272
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* = required
1
Boy Scout Claimant Name
Name of person who was in Scouting:
First Name
*
Example: John
Last Name
*
Example: Smith
SST Number (if known)
Example: 57856
2
Relationship to Claimant
My relationship to the Boy Scout Claimant was as:
Parent
Sibling
Neighbor
Scoutmaster/Assistant Scoutmaster
Volunteer with Scouting
Fellow Scout
Classmate
Teacher
Friend
Other (please explain)
Check All That Apply
If Other: Please explain your relationship to the Claimant
3
Your Information
Please provide your contact information in case further information is needed:
First Name
*
Example: John
Last Name
*
Example: Smith
Address
*
Example: 1234 Somewhere Ave.
City
*
Example: Houston
State
*
Select
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Example: Texas
Zip Code
*
Example: 77002
Phone
*
Example: 5555551234
E-Mail
*
Example: someone@someplace.com
4
Scoutmaster, Volunteer or Other Person Connection to Scouting
Please provide the name of the Scoutmaster/Volunteer/Person that was in Boy Scouts with the claimant:
First Name
*
Example: John
Last Name
*
Example: Smith
I know the above person was connected to Scouting because he was a:
Scoutmaster
Volunteer or someone I saw attend Scouting activities
Parent of a fellow Scout
Sibling of a fellow Scout
Scoutmaster or leader of another troop
Someone I saw wear a Scouting uniform
Other
Check All That Apply
If Other: Please describe:
Describe how you know the above person was connected to Scouting
*
Examples:
I am his mom and I met his [Scoutmaster] at meetings and at school.
I am his dad and I met his [camp counselor] when I dropped him off at camp and remember his counselor had red hair and a scar on his chin;
I was [Scoutmaster's] neighbor and saw him in his uniform all the time;
I was a scout in the same troop and the [Scoutmaster] was my Scoutmaster too;
I was [Claimant's] bunkmate at Camp and remember receiving my swimming badge from [Counselor];
I attended the Pinewood Derby with [Claimant] and I remember our Scout Leader for the weekend was a heavy man named [Joe];
I worked with [Scoutmaster] and knew he was a Scoutmaster of the troop because he would talk about it and hold meetings at his house after school.)
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If Need Help Call 215-515-5272