Adventurer Registration 2021-2022

Miami Temple Messengers Adventurer Club

Member Registration Form
Member Information
Member's Name *

First Name Last Name
Member Birthdate *

Month Day Year
Date
Age
Today

Month Day Year
Date
Default date 9/1/21

Month Day Year
Date
Gender *
Baptized?
School
Grade in 2021 - 2022 Year
Home Church
Highest Level of Investiture
Member's Address

Street Address

Street Address Line 2

City State

Zip Code
Member has been an Adventurer Before?

Yes No
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
Please help your member memorize the Adventurer Pledge and Law
Adventurer Pledge:

Because Jesus loves me I will always do my best.
Adventurer Law:

Jesus can help me to:
- Be obedient
- Be pure
- Be true
- Be kind
- Be respectful
- Be attentive
- Be helpful
- Be cheerful
- Be thoughtful
- Be reverent

Dismissal Authorization
To ensure each child's safety. Adventurers will be dismissed from club functions only to the authorized family members or guadian which appear on this form
Member's Current Class
Authorized Persons
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship
2nd Authorized Person
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship
3rd Authorized Person
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship
Any additional information we should know

Virtual Group Agreement
As the parent of legal guardian of the MT Adventurer indicated on the form, I grant permission for Miami Temple Adventuer Club to engage my child in the use of video and audio conferencing with the Miami Temple Adventurer Club. These small groups are comprised of the Adventurers that would normally be included in their live discussions at Miami Temple SDA Church. These groups will be supervised and managed by the screen and trained club leaders/counselors.

MT ADVENTURER CLUB COMMUNICATIONS AGREEMENT

As the parent or legal guardian of the student indicated on the form, I gran permission for Miami Temple Adventurer Club to engage my child and myself through text messaging at the number provided on thier intake form. These text messages will be for the purpose of shareing Adventurer Club content. This service is optional, and text messaging rates may apply-those are not the responsibility of Miami Temple SDA Church.
My student has permission to participate in Miami Temple Virtual Adventurer Club.

Yes No
I consent to receive text messages from the Miami Temple Adventurer Club as needed for my child.

Yes No

Photo Release Agreement
I do hereby voluntarily waive, grant, and release the right to photograph and publish pictures, audio and video of me and/or my child or children (listed below) to the Florida Conference of Seventh-day Adventists. I understand that photographs may be printed, placed on the organization's various websites, or incorporated into promotional material such as brochures or videos.

I hereby waive any claim against the Florida Conference of Seventh-day Adventists for any personal or emotional damage which may arise in connection with the use of the photographs.

I understand that illegal or explicit photographs are NOT authorized under this agreement. Should such a situation arise, it is understood that it is not the result of negligence on the part of the Florida Conference of Seventh-day Adventists. In such a case the violating individual or parties are solely liable and are subject to all local, state, and federal laws.

I understand that by signing this form, I am releasing all recorded images and audios for the express use of the Florida Conference of Seventh-day Adventists. Neither my child nor I will receive any compensation for this now or at any time in the future. I further certify that I am the parent or guardian of the child and am over 18 years of age. I understand that the Florida Conference of Seventh-day Adventists and the photographer(s) will hold the copyright to all photographs.

Should I desire a copy of one or more photographs, videos or audios, I will make a request to the appropriate person verbally or in writing.
I agree with the Photo Release Agreement

Yes No
Approval of Parent(s) / Guardian(s)

The applicant is in Pre-K through 4th grade at time of registration. We have read the Pledge and Law and are willing and desirous that the applicatn become an Adventurer. We will assist the application in observing the rules of the Adventurer organization. As parents, we understand that the Adventurer Club program is an active one for the applicant. It incudes many opportunities for services, adventurer, and fun. We will cooperate by:
1. By learning ow we can assist the applicant and his/her leaders.
2. By encouraging the application to take an active part n all club activities.
3. By attending events to which parents are invited.
4. By assisting club leaders and by serving as leaders if called upon.
We hereby certify that all information stated is valid and truthful.
Mother or Guardian Signature

Clear
Date Signed

Month Day Year
Date
If your device has a camera click the Take Photo button below
Father's Signature

Clear
Date Signed

Month Day Year
Date
If your device has a camera click the Take Photo button below

Medical Consent Form
Member's Name

First Name Last Name
Member Birth Date *

Month Day Year
Date
Gender
Member's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Medical Insurance Company
Member Number / Policy Number
Group Number
Child's Physician's Name
Physician's Phone Number
Please enter a valid phone number.

ADVENTURER MEDICAL HISTORY
Weight
Height
Date of Last Tetanus Shot

Month Day Year
Date
Known Medication Allergies
Current Medications
Medical History (Major surgeries, chronic illness, asthma, diabetes, hemophilia, etc.)

EMERGENCY CONTACT

(IN CASE PARENTS ARE UNAVAILABLE)
Name

First Name Last Name
Relationship to Adventurer
Cell Phone Number
Please enter a valid phone number.
CONSENT TO TREAT
I, First Name Last Name (parent / guardian), give the following consent for emergency medical treatment for the above named minor. This shall be in effect from August 2021 - June 2022

(Español - Doy siguiente consentimiento para el tratamiento médico de emergencia para el menor mencionado anteriormente. Estará en vigor desde agosto de 2021 hasta junio de 2022.)
*

Emergency Surgery First Aid Both Emergency Surgery and First Aid Neither Emergency Surgery nor First Aid
Email for response. Please enter the email you would like the completed form to be sent to:
example@example.com
Please click the Submit button below then check your email for a PDF version of this form. Print the form and sign in front of a Notary Public.

Parent / Guardian Signature: _______________________________

________________________________

Date: ___________________
NOTARY

Subscribed and acknowledged before me this ________ day of

____________, 20___ by ___________________________

who is personally known to me or has produced _________________

_________________________ as identification.
Serena Email
example@example.com
Should be Empty:

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Miami Temple Messengers Adventurer Club

Member Information

Parent / Guardian Information

Dismissal Authorization

Virtual Group Agreement

Photo Release Agreement

Medical Consent Form

ADVENTURER MEDICAL HISTORY

EMERGENCY CONTACT

CONSENT TO TREAT