Application

SECC PATHFINDERS Membership Application

LLKSDA Church Applicant Information

1.Name:                                          Circle: Staff/ Master Guide/ Teen Counselor/ Member             Invested/Training

Current Address:

City:

Zip Code:

Phone:

Date of Birth:

Age:

Grade:

Email:

Baptized?

School:

Allergies:

Meds:

Medical Restrictions:

Physician Name:

Phone:

Ins. Carrier & Policy #:


ADDITIONAL MEMBER

2.Name:

Date of birth:

Age:

Grade:

Email/Phone:

Baptized?

School:

Allergies:

Meds:

Medical Restrictions:

Physician Name:

Phone:

Ins. Carrier & Policy #:

ADDITIONAL MEMBER

3.Name:

Date of birth:

Age:

Grade:

Email/Phone:

Baptized?

School:

Allergies:

Meds:

Medical Restrictions:

Physician Name:

Phone:

Ins. Carrier & Policy #:

Print Name:


Emergency/PARENT  Contact

Mother:                                                         Phone:                               Email:

Father:                                                           Phone:                               Email:

Alternate Emergency Contact:                      Phone:                               Relationship to children:

 

I authorize the verification of the information provided on application form.

Parent Signature:

Date:

 

 

Circle #children

Payment Date

First child

2nd child

3rd child

Sep. 14, 2019 (Deadline)

$135

$110

$95

After Sep. 15, 2019 (Late Fee)

+ $15

 + $15

 + $15

 

Total Due:_____________________________________

Consent

PARENTAL CONSENT

  • Authorization for emergency treatment:

I the undersigned parent/legal guardian having legal custody of the above named minor, do hereby authorize and con- sent to any X-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act or a Dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power to render care which is the aforementioned physician in the exercise of his best judgment may deem advisable.  It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. This authorization is given pursuant to the provisions of section 25.8 of the Civic Code of California.

 

  • Consent for child/children’s participation:

I understand that membership will include participation in planned activities. While every reasonable step will be taken to ensure these activities are as safe as possible, I understand that there are inherent risks associated with these activities which may result in serious injury or death. I consent for my child to participate in these activities and assume full responsibility for the inherent risks which exist.

 

I also agree to indemnify and hold harmless the sponsoring institute, Southeastern California Conference of Seventh-day Adventists and sponsors from liability arising from accident or injury arising from negligence on the part of those mentioned above. This recognizes a shared responsibility among church, student and home. This does not include gross negligence on the part of those mentioned above. This does not waive coverage within the policy limits of church accident insurance, which covers church sponsored activities.

 

I further understand that it is not mandatory for my child to participate in all of the activities planned for this trip provided

I specify below what restrictions if any I request be placed on my child for purposes of participation in this trips activities.

Specific Restrictions Include: __________Approval/Consent of Parent/Guardian

 

  • Parent support of the Pathfinder program:

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

 

  • Encouraging my Pathfinder to take an active part in all club meetings and functions

 

  • Attending all events to which parents are invited in support of my Pathfinder

 

  • Assisting club leaders by serving as a helper when needed

 

  • Not holding any individual club staff member liable in the event of injury

 

  • Giving my permission for the above named Pathfinder to attend all Pathfinder activities

 


 

 

Payment Date

1st child

2nd child

3rd child

  


By September 14, 2019

$135

$110

$95

  

Late fee (After 9/15/19)

Fee + $15

Fee + $15

FEE + $15

Total

Sub-Total

 

 

 

 

 


 

 

 

                                                                                 

(parent/guardian’s signature)

 

Commitment

Applicant No. 1

2019-2020 PATHFINDER COMMITMENT

 

I,                                           , want to join the  LLKSDA Pathfinder Club .  I will attend all “Share Your

                                                            (applicant’s name)

Faith” activities, outings, and other club activities, unless I am ill.  I will proudly wear my Pathfinder uniform.  I will obey club rules and understand that they have been made for my safety and that of my peers.  I will be cheerful, helpful, honest, kind and courteous.





  __________________________________


(applicant’s signature)


Applicant No. 2

2019-2020 PATHFINDER COMMITMENT

 

I,                                           , want to join the  LLKSDA Pathfinder Club .  I will attend all “Share Your

                                                            (applicant’s name)

Faith” activities, outings, and other club activities, unless I am ill.  I will proudly wear my Pathfinder uniform.  I will obey club rules and understand that they have been made for my safety and that of my peers.  I will be cheerful, helpful, honest, kind and courteous.

 


                                                                

(applicant’s signature)

 

 

 

Applicant No. 3

2019-2020 PATHFINDER COMMITMENT

 

I,                                           , want to join the  LLKSDA Pathfinder Club .  I will attend all “Share Your

                                                            (applicant’s name)

Faith” activities, outings, and other club activities, unless I am ill.  I will proudly wear my Pathfinder uniform.  I will obey club rules and understand that they have been made for my safety and that of my peers.  I will be cheerful, helpful, honest, kind and courteous.

 


                                                                              

(applicant’s signature)