BSP FORM No.

6-03
(Revised 30 Jan 2020) NATIONAL OFFICE COPY
BOY SCOUTS OF THE PHILIPPINES
181 Natividad Almeda-Lopez Street, Ermita, Manila 1000

APPLICATION FOR ADULT REGISTRATION

AAR NO.

Name: DOMINGO LEOPOLDO JR T. Sex: MALE Civil Status: SINGLE

Surname First Name M.I
Tenure in Scouting: 5 Membership Card No. Expiration Date _ _
To serve as: _ OUTFIT ADVISOR_ _
Scouting Position Unit No.

STA. CRUZ INTEGRATED SCHOOL_ EASTERN PANGASINAN COUNCIL

Sponsoring Institution Council
Mailing Address _____________________________________________________________
Date of Birth: _ APRIL 12, 1993 Place of Birth: Rosales, Pangasinan Religion: Evangelical Christian
Profession/Occupation: Teacher Position/Title: Teacher I _
Other Affiliations: _ _ Registration status: New Reregistering

SAFE FROM HARM

World Scouting emphasizes that the achievement of Scouting’s Mission makes it essential for the Movement to
provide young people with a “safe passage” based on respect for their integrity and their right to develop in a
non- constraining environment. The Boy Scouts of the Philippines implements “Safe from Harm” on the
conviction that all adults and children have a right NOT to be abused. This is a fundamental human right. Abuse
can take the form of bullying, physical abuse, emotional abuse, neglect, sexual abuse and exploitation. It is
important to note that young people can suffer from one or a combination of these forms of abuse. Abuse can
take place at home, at school or anywhere young people spend time. In the great majority of cases, the abuser is
someone the young person knows, such as a parent, teacher, relative, leader or friend. The main objective is to
ensure that no one will be exposed to abuse. Good child protection practice means making sure that everyone is
aware of signs of potential abuse. It is based upon the Declaration on the Rights of the Child and Human Rights.
I hereby commit and fully subscribe to the existing Safe From Harm Policy of the Boy Scouts of the
Philippines, and that I hereby absolve and free the BSP from any liability arising from any of my acts contrary
to the policy. I hereby accept that the BSP may immediately revoke my registration as an adult leader upon
violation of such policy.
LEOPOLDO T. DOMINGO JR.
Signature Over Printed Name

REGISTRATION FEES LOCAL COUNCIL OFFICE ACTION

Please check one; RATE Processed :
Registration Officer Date
LCEB Members 500.00
UL/AUL 60.00 Approved :
Council Scout Executive Date
Lay Leaders 100.00
REGIONAL OFFICE ACTION
AMOUNT PAID
Checked :
Paid Under OR. No. Date Registration Officer Date
 BSP FORM No. 6-03
(Revised 30 Jan 2020) REGIONAL OFFICE COPY
BOY SCOUTS OF THE PHILIPPINES
181 Natividad Almeda-Lopez Street, Ermita, Manila 1000

APPLICATION FOR ADULT REGISTRATION

AAR NO.

Name: DOMINGO LEOPOLDO JR T. Sex: MALE Civil Status: SINGLE

Surname First Name M.I
Tenure in Scouting: 5 Membership Card No. Expiration Date _ _
To serve as: _ OUTFIT ADVISOR_ _
Scouting Position Unit No.

STA. CRUZ INTEGRATED SCHOOL_ EASTERN PANGASINAN COUNCIL

Sponsoring Institution Council
Mailing Address _____________________________________________________________
Date of Birth: _ APRIL 12, 1993 Place of Birth: Rosales, Pangasinan Religion: Evangelical Christian
Profession/Occupation: Teacher Position/Title: Teacher I _
Other Affiliations: _ _ Registration status: New Reregistering

SAFE FROM HARM

World Scouting emphasizes that the achievement of Scouting’s Mission makes it essential for the Movement to
provide young people with a “safe passage” based on respect for their integrity and their right to develop in a
non- constraining environment. The Boy Scouts of the Philippines implements “Safe from Harm” on the
conviction that all adults and children have a right NOT to be abused. This is a fundamental human right. Abuse
can take the form of bullying, physical abuse, emotional abuse, neglect, sexual abuse and exploitation. It is
important to note that young people can suffer from one or a combination of these forms of abuse. Abuse can
take place at home, at school or anywhere young people spend time. In the great majority of cases, the abuser is
someone the young person knows, such as a parent, teacher, relative, leader or friend. The main objective is to
ensure that no one will be exposed to abuse. Good child protection practice means making sure that everyone is
aware of signs of potential abuse. It is based upon the Declaration on the Rights of the Child and Human Rights.
I hereby commit and fully subscribe to the existing Safe From Harm Policy of the Boy Scouts of the
Philippines, and that I hereby absolve and free the BSP from any liability arising from any of my acts contrary
to the policy. I hereby accept that the BSP may immediately revoke my registration as an adult leader upon
violation of such policy.
LEOPOLDO T. DOMINGO JR.
Signature Over Printed Name

REGISTRATION FEES LOCAL COUNCIL OFFICE ACTION

Please check one; RATE Processed :
Registration Officer Date
LCEB Members 500.00
UL/AUL 60.00 Approved :
Council Scout Executive Date
Lay Leaders 100.00
REGIONAL OFFICE ACTION
AMOUNT PAID
Checked :
Paid Under OR. No. Date Registration Officer Date
 BSP FORM No. 6-03
(Revised 30 Jan 2020) LOCAL COUNCIL COPY
BOY SCOUTS OF THE PHILIPPINES
181 Natividad Almeda-Lopez Street, Ermita, Manila 1000

APPLICATION FOR ADULT REGISTRATION

AAR NO.

Name: DOMINGO LEOPOLDO JR T. Sex: MALE Civil Status: SINGLE

Surname First Name M.I
Tenure in Scouting: 5 Membership Card No. Expiration Date _ _
To serve as: _ OUTFIT ADVISOR_ _
Scouting Position Unit No.

STA. CRUZ INTEGRATED SCHOOL_ EASTERN PANGASINAN COUNCIL

Sponsoring Institution Council
Mailing Address _____________________________________________________________
Date of Birth: _ APRIL 12, 1993 Place of Birth: Rosales, Pangasinan Religion: Evangelical Christian
Profession/Occupation: Teacher Position/Title: Teacher I _
Other Affiliations: _ _ Registration status: New Reregistering

SAFE FROM HARM

World Scouting emphasizes that the achievement of Scouting’s Mission makes it essential for the Movement to
provide young people with a “safe passage” based on respect for their integrity and their right to develop in a
non- constraining environment. The Boy Scouts of the Philippines implements “Safe from Harm” on the
conviction that all adults and children have a right NOT to be abused. This is a fundamental human right. Abuse
can take the form of bullying, physical abuse, emotional abuse, neglect, sexual abuse and exploitation. It is
important to note that young people can suffer from one or a combination of these forms of abuse. Abuse can
take place at home, at school or anywhere young people spend time. In the great majority of cases, the abuser is
someone the young person knows, such as a parent, teacher, relative, leader or friend. The main objective is to
ensure that no one will be exposed to abuse. Good child protection practice means making sure that everyone is
aware of signs of potential abuse. It is based upon the Declaration on the Rights of the Child and Human Rights.
I hereby commit and fully subscribe to the existing Safe From Harm Policy of the Boy Scouts of the
Philippines, and that I hereby absolve and free the BSP from any liability arising from any of my acts contrary
to the policy. I hereby accept that the BSP may immediately revoke my registration as an adult leader upon
violation of such policy.
LEOPOLDO T. DOMINGO JR.
Signature Over Printed Name

REGISTRATION FEES LOCAL COUNCIL OFFICE ACTION

Please check one; RATE Processed :
Registration Officer Date
LCEB Members 500.00
UL/AUL 60.00 Approved :
Council Scout Executive Date
Lay Leaders 100.00
REGIONAL OFFICE ACTION
AMOUNT PAID
Checked :
Paid Under OR. No. Date Registration Officer Date
 BSP FORM No. 6-03
(Revised 30 Jan 2020) SPONSORING INSTITUTION COPY
BOY SCOUTS OF THE PHILIPPINES
181 Natividad Almeda-Lopez Street, Ermita, Manila 1000

APPLICATION FOR ADULT

AAR NO.
REGISTRATION
Name: DOMINGO LEOPOLDO JR T. Sex: MALE Civil Status: SINGLE
Surname First Name M.I
Tenure in Scouting: 5 Membership Card No. Expiration Date _ _
To serve as: _ OUTFIT ADVISOR_ _
Scouting Position Unit No.

STA. CRUZ INTEGRATED SCHOOL_ EASTERN PANGASINAN COUNCIL

Sponsoring Institution Council
Mailing Address _____________________________________________________________
Date of Birth: _ APRIL 12, 1993 Place of Birth: Rosales, Pangasinan Religion: Evangelical Christian
Profession/Occupation: Teacher Position/Title: Teacher I _
Other Affiliations: _ _ Registration status: New Reregistering

SAFE FROM HARM

World Scouting emphasizes that the achievement of Scouting’s Mission makes it essential for the Movement to
provide young people with a “safe passage” based on respect for their integrity and their right to develop in a
non- constraining environment. The Boy Scouts of the Philippines implements “Safe from Harm” on the
conviction that all adults and children have a right NOT to be abused. This is a fundamental human right. Abuse
can take the form of bullying, physical abuse, emotional abuse, neglect, sexual abuse and exploitation. It is
important to note that young people can suffer from one or a combination of these forms of abuse. Abuse can
take place at home, at school or anywhere young people spend time. In the great majority of cases, the abuser is
someone the young person knows, such as a parent, teacher, relative, leader or friend. The main objective is to
ensure that no one will be exposed to abuse. Good child protection practice means making sure that everyone is
aware of signs of potential abuse. It is based upon the Declaration on the Rights of the Child and Human Rights.
I hereby commit and fully subscribe to the existing Safe From Harm Policy of the Boy Scouts of the
Philippines, and that I hereby absolve and free the BSP from any liability arising from any of my acts contrary
to the policy. I hereby accept that the BSP may immediately revoke my registration as an adult leader upon
violation of such policy.
LEOPOLDO T. DOMINGO JR.
Signature Over Printed Name
REGISTRATION FEES LOCAL COUNCIL OFFICE ACTION
Please check one; RATE Processed :
Registration Officer Date
LCEB Members 500.00
UL/AUL 60.00 Approved :
Council Scout Executive Date
Lay Leaders 100.00
REGIONAL OFFICE ACTION
AMOUNT PAID
Checked :
Paid Under OR. No. Date Registration Officer Date
BSP FORM No. 6-03

REGISTRATION FEES LOCAL COUNCIL OFFICE ACTION

Please check one; RATE Processed :
Registration Officer Date
LCEB Members 500.00
UL/AUL 60.00 Approved :
Council Scout Executive Date
Lay Leaders 100.00
REGIONAL OFFICE ACTION
AMOUNT PAID
Checked :
Paid Under OR. No. Date Registration Officer Date