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To be completed by BSA Leader Council Name: Address:1. PLEASE FULLY COMPLETE THIS FORM 2. ATTACH ITEMIZED BILLS WITH DOCTORS DIAGNOSIS 3. MAIL TO HEALTH SPECIAL RISK, INC. HER Plaza 4100 Medical Parkway

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Anyone who is involved with the Boy Scouts organization and is responsible for registering or updating the information of a council, such as council leaders, administrators, or volunteers, would need to fill out the council name for Boy Scouts form.

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Council name boy scouts refers to the official name of the local scout council.

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