SECC PATHFINDERS Membership Application |
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LLKSDA Church Applicant Information |
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1.Name: Circle: Staff/ Master Guide/ Teen Counselor/ Member Invested/Training |
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Current Address: |
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City: |
Zip Code: |
Phone: |
Date of Birth: |
Age: |
Grade: |
Email: |
Baptized? |
School: |
Allergies: |
Meds: |
Medical Restrictions: |
Physician Name: |
Phone: |
Ins. Carrier & Policy #: |
ADDITIONAL MEMBER |
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2.Name: |
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Date of birth: |
Age: |
Grade: |
Email/Phone: |
Baptized? |
School: |
Allergies: |
Meds: |
Medical Restrictions: |
Physician Name: |
Phone: |
Ins. Carrier & Policy #: |
ADDITIONAL MEMBER |
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3.Name: |
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Date of birth: |
Age: |
Grade: |
Email/Phone: |
Baptized? |
School: |
Allergies: |
Meds: |
Medical Restrictions: |
Physician Name: |
Phone: |
Ins. Carrier & Policy #: |
Print Name: |
Emergency/PARENT Contact |
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Mother: Phone: Email: | |
Father: Phone: Email: | |
Alternate Emergency Contact: Phone: Relationship to children: | |
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I authorize the verification of the information provided on application form. | |
Parent Signature: |
Date: |
Circle #children
Payment Date |
First child |
2nd child |
3rd child |
August 20, 2022 (Deadline)
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$80 |
$80 |
$80 |
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Total Due:_____________________________________