Crazy Horse Lodge #171
Member Information Sheet
Name: ________________________________________________
Address: ______________________________________________
E-Mail (if applicable): ____________________________________
Phone Num (home): _______________ (work): ________________
Date of Birth: ________________ Place of Birth: _______________
Youth - Member of Troop #: _________
Adult - Current Scouting Position:
Pack #
Troop #
Post #
District/Council
Current OA Membership Status:
Ordeal: _____ Brotherhood: _____ Vigil: _____
Date of Ordeal: _______________
Location of Ordeal:
City: _____________________ State: __________
Council: ________________ Lodge: ____________
Date of Brotherhood: __________
Location of Brotherhood:
City: _____________________ State: __________
Council: ________________ Lodge: ____________
Date of Vigil: __________
Location of Vigil:
City: _____________________ State: __________
Council: ________________ Lodge: ____________
Date of Vigil: __________
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