test General Information Image Release Volunteer Health Record Pathfinder Information Pathfinder Name First Name * Last Name * Date of Birth * School Grade 6th7th8th9th10th11th12th Church I have been a Pathfinder? YesNo Where? Has any parent / guardian been a Pathfinder? YesNo Where? My parent / guardian is a Master Guide? YesNo Where? Pathfinder Signature: * Clear Approval By Parents or Guardians: The applicant is at least 10 years of age or in the 5 grade as a Junior Pathfinder, or in grade 7 as a Teen Pathfinder. We have read the Pathfinder Pledge and Law and are willing and desirous that the applicant become a Pathfinder. We will assist the applicant in observing the rules of the Pathfinder organization. In consideration of the benefits derived from membership, we hereby voluntarily waive any claim against the club or the Allegheny East Conference of Seventh-day Adventists for any accidents which may arise in connection with the activities of the Pathfinder club. As the parents or guardians, we understand that the Pathfinder Club program is an active one for the applicant. It includes many opportunities for service, adventure, and fun. We will cooperate: By learning how we can assist the applicant and his leaders. By encouraging the applicant to take an active part in all activities. By attending events to which parents are invited. By assisting club leaders and by serving as leaders if called upon. By purchasing Pathfinder insurance through the club treasurer. * By supplying needed information on the Membership Application and Health Record. *Insurance is already supplied by the church once you become a member of the club I certify that was born on Parent / Guardian's Contact Information Parent / Guardian's Name First Name * Last Name * Email * Parent / Guardian's Phone * Select Phone Type * HomeCell Relation to pathfinder? MotherFatherAuntUncleOther Other relation? Address Street Address * City * State / Province * Postal / Zip Code * Signature of Parent / Guardian * Clear Previous Next I hereby Consent toDo Not Consent to 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. releasing Allegheny East Conference of Seventh-day Adventists from all liability in connection with such uses. [conditional] Address Street Address * City * State / Province * Postal / Zip Code * Parent / Guardian's Phone * Select Phone Type * HomeCell Signing Date Parent / Guardian Name * Signature of Parent / Guardian * Clear Witness Name Signature of Witness Clear Previous Next Are you interested in being a volunteer or staff for the Pathfinder Club? Yes, I would like to join the staffYes, I would like to volunteer Previous Next Pathfinder Health Information Pathfinder Name First Name * Last Name * Date of Birth * 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 Parent / Guardian's Name * Parent / Guardian's Phone * Select Phone Type * HomeCell Physician's Contact Information Physician's Name * Physician's Phone Number * Physician Address Street Address * City * State / Province * Postal / Zip Code * 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 Clear Signature Date * Previous Next Leave a Reply Cancel replyYour email address will not be published. Required fields are marked *Comment * Name * Email * Website Save my name, email, and website in this browser for the next time I comment.
