SHOOTING STARS

Adventurer Club Application Form

Registration Fee: $55.00 for 1st child , $45 for 2nd child, $35 for 3rd child.

*If financial assistance is needed, please contact your club director

Pay on Adventist Giving

General Information

Image Release

Volunteer

Health Record

Adventurer Information

Adventurer Name

First Name * Last Name *

Date of Birth *

Age*

School

Grade

Church

I want to join the Shooting Stars Adventurer Club. I will attend meetings, activities, field trips, and other club activities. I will proudly wear my Adventurer uniform and obey club guidelines. I will be cheerful, helpful, honest, kind and courteous. Signature of Adventurer*

Adventurer Signature: *

Parent / Guardian's Contact Information

Parent / Guardian's Name

First Name * Last Name *

Parent / Guardian's Email *

Parent / Guardian's Phone * Select Phone Type *

Relation to pathfinder? *

Other relation?

Address

Street Address *

City * State / Province *

Postal / Zip Code *

Approval/Consent of Parent/Guardian

As parent/guardian, we understand that the Adventurer program is an active one which includes many opportunities for service, adventure, fund, and learning. I will support the program by:

Encouraging my Adventurer to take an active part in all club meetings and functions.
Attending events to which parents are invited in support of my Adventurer.
Assisting club leaders by serving as a helper when needed.
Not holding any individual club staff member liable in the event of an accidental injury.
Giving my permission for the above-named Adventurer to attend Adventurer activities.

Signature of Parent / Guardian *

I hereby

allowing the Allegheny East conference of Seventh-day Adventists ("AEC), or its assigns, to use my name and/or the names of my family members who are minors, as listed below, as well as my likeness, photos, videos and other information (or that of family members who are minors) for the purpose of news releases, advertising, publicity, publication or distribution in any manner whatsoever.
such use in their present form and to any changes, alterations, or additions thereto.

Are you interested in becoming a volunteer or staff member for the Shooting Stars Adventurer Club?

Adventurer Health Information

Adventurer Name

First Name * Last Name *

Date of Birth *

Age

Grade

Insurance Company Name Insurance Policy Number

Date of last Tetanus Booster

Allergies to Drugs or Food

Special medications or pertinent information

List Any Restrictions

Parent / Guardian's Contact Information

Name *

Phone * Select Phone Type *

Address

Street Address *

City * State / Province *

Postal / Zip Code *

Family Physician / Pediatrician Contact Information

Name *

Phone

Address

Street Address *

City * State / Province *

Postal / Zip Code *

Authorization to Treat a Minor

I (we) the undersigned parent/parents or legal guardian of .

In case of emergency, I hereby give permission to the physician selected by the club directors to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child. As parent or legal guardian of the applicant, I am in favor of him/her attending club functions and accept the conditions named. The health history stated is correct so far as I know, and the person herein described has permission to engage in all prescribed club activities except as noted. In addition, I have read and understand the Emergency Authorization statement and give my full consent to the terms found therein. Permission for photocopying or printing of this health record is granted. Signature of parent/guardian

Signature Date *

SHOOTING STARS

Adventurer Club Application Form

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