By checking this box, I attest to understanding that while this event does have some
indoor 'classroom-style'
sessions, the most important experience of the Conference is the Brotherhood gained through leadership
and team building activities.
By checking this box, I attest to understanding that this form constitutes an
application and does not guarantee admission.
Personal Profile Information
First Name:
Last Name:
Date of Birth:
--
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
--
01
02
03
04
05
06
07
08
09
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1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Shirt Size:
--
S
M
L
XL
2XL
3XL
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
Home Phone:
(xxx) xxx-xxxx
Email:
DeMolay Career Information
Chapter:
--
Out of State
Allegiance
Carondelet
Crestwood
Daniel Boone
Divine
Excelsior
Farnsworth
Frank S. Land
George L. Walters
Independence
Jefferson
Joplin
Kirkwood
Mineral Area
Mochila
Mother
Perfection
Progression
Rising Sun
St. Charles
Sullivan
Waynesville
William F. Kuhn
Chapter Advisor's Name:
Chapter Advisor's Email:
Current Office:
--
Master Councilor
Senior Councilor
Junior Councilor
Senior Deacon
Junior Deacon
Senior Steward
Junior Steward
Orator
Scribe
Treasurer
Sentinel
Chaplain
Marshal
Standard Bearer
Almoner
Preceptor
Past Master Councilor
State/Jurisdictional Officer
Received Initiatory Degree?
Date:
--
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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01
02
03
04
05
06
07
08
09
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12
13
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21
22
23
24
25
26
27
28
29
30
31
--
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Received the DeMolay Degree?
Date:
--
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
--
01
02
03
04
05
06
07
08
09
10
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31
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2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Obligations Turned In?
Past Master Councilor?
Current LCC Level:
0
1
2
3
4
5
Honors and Awards: check all that apply
Founder's Membership Award
Blue Honor Key
Past Master Councilor's Meritorious Service Award
Representative DeMolay
Chevalier
Number of Members Recruited:
--
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
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43
44
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48
49
50
Previous Leadership Program Experience:
--
None
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
Note: preference will be given to young men who have NOT attended in prior years.
Please list any and all parts known from memory of the DeMolay Ritual or Monitor of Ceremonies:
Personal Analysis
Why would you be a good choice to attend?
If selected to attend, what do you hope to gain while in attendance?
What do you see as your three strongest leadership characteristics?
What DeMolay program would you like to improve and how?
Health/Medical Information
Health Issues:
Sinus Trouble
Fainting
Appendicitis
Cramps in Water
Allergies
Frequent Colds
Hernia (Rupture)
Throat Infections
Diabetes
Convulsions
Ear Trouble
Heart Disease
Epilepsy
Autism
ADD / ADHD
Sleep Apnea
If any health issues are checked, please describe in detail:
Other illnesses or issues not checked above that DeMolay should be aware of:
Are you currenlty under care for any illness or injury? If so, explain in detail:
Have you had any surgeries or significant injuries in the past 12 months? If so, explain in detail:
List any and all medications currently being taken:
List any and all known allergies:
List other conditions or concerns we should be aware of:
Emergency Contact Information
Emergency Contact #1 (Parent):
Emergency Contact #1 Phone 1:
Emergency Contact #1 Phone 2:
Emergency Contact #2 (Other):
Emergency Contact #2 Phone 1:
Emergency Contact #2 Phone 2:
Insurance Information
Insurance Carrier:
Insurance Policy #:
Relationship to Insured:
Insurance Company Phone #:
Primary Care Physician Name:
Primary Care Physician Phone #:
Final Submission
By checking this box, I hereby attest that the information provided herein is
representative of me and that every field of data has been answered thoroughly and
truthfully.
By checking this box, I hereby attest that I have permission granted from my
Parent(s)/Guardian(s) and Chapter Advisor(s) [and for out-of-state applicants, my
Executive Officer] to submit this scholarship application.
Furthermore, I, and they, agree to endorse all necessary forms should I be selected
to receive a scholarship to attend The University of DeMolay.