Pleasant Valley Pathfinder Club

ATTENTION:

Please review the document and understand what you are signing. This is a legal document.

Please fill out the form as completely and accurately as possible (not just the required fields).

Make sure you have your insurance information on hand before you start!
Pathfinder Information
Pathfinder Full Name*
Age*
Birth Date*

MonthDayYear
Date
Sex*

MaleFemale
Address*

Address

Street Address Line 2

CityState

Zip Code
Parent Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Grade in school*
Parent / Legal Guardian(s) Name (Father)
Parent / Legal Guardian(s) Name (Mother)
Pathfinder Club*
Event Details
Event:*
Event Date:*

MonthDayYear
Date
Event Location:*
Insurance and Medical
Family Insurance Company:
Family Insurance Policy Number:
Allergies: Please list all allergies your child has:
Medications: Please list all medications your child takes:
Physical Conditions: Please list any conditions that limit your child's participation in this event:
Please list any dietary requirements and/or allergies that must be observed:
Signature
(Parent/Guardian Signature)
(Date)*

MonthDayYear
Date
(Parent/Guardian Name — please print)*
Parent's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Pathfinder Information