Pathfinder Application Form

Image Release Form
For no compensation, I hereby consent and authorize 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 whatesoever. I further consent to such use in their present form and to any changes, alterations, or additions thereto. I hereby release the Allegheny East Conference of Seventh-day Adventists from all liability in connection with such uses.
Date

MonthDayYear
Date
Print Name
Signature

Powered by Jotform SignClear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name of Witness
Signature of Witness

Powered by Jotform SignClear

Pathfinder Club Staff and Parent Volunteer Information
Are you or guardian interested in being a parent volunteer or staff for the Shooting Stars Adventurer Club?*

YesNo
I will complete the background screening and training required by our conference.

Yes
Parent and Volunteer Information
Name

First NameLast Name
Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Church
Name and Birth Date of Spouse (If applicable)
Health History
Do you have any injury/sickness that might limit your involvement in Adventurer Club Activities?

YesNo
How would it hinder?
Education Record
Highest degree/diploma earned
School granting degree/diploma
College major/minor
Experience
List all experience working with children (Pathfinders, Scouts, Sabbath School, etc. Include position or type of work, Church/organization, Date of service)
Instruction Ability
List the level, patch or craft you are interested in teaching. Indicate if you are capable of T-Teaching, A-Assisting, or I-Interested in teaming to teach.
Unlawful Conduct
Have you been accused, charged, or disciplined for any unlawful sexual oonduct, child abuse, and/or child sexual abuse?

YesNo
Date/Place
Type of conduct
Reference name, address, and phone
References (for regular staff only)
List three individuals who know you well enough to recommend you as an Adventurer staff member. (1. Pastor 2. Local teacher 3. Other. Include Name, Address and Phone)
Statement of Accuracy
The above information is accurate to the best of my recollection. I understand this is scrictly a volunteer position, and I will receive no remuneration for services and time volunteered.
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date

Pathfinder Club Health Record
Please attach or return a copy of your child's insurance card

Cancelof
Name of Pathfinder

First NameLast Name
Birth Date

MonthDayYear
Date
Insurance company and Policy Number
Date of last Tetanus Booster

MonthDayYear
Date
Allergies to Drugs or Food
Special medications or pertinent information
List Any Restrictions
Father's Home Phone
Please enter a valid phone number.
Father's Cell Phone
Please enter a valid phone number.
Father's Work Phone
Please enter a valid phone number.
Mother's Home Phone
Please enter a valid phone number.
Mother's Cell Phone
Please enter a valid phone number.
Mother's Work Phone
Please enter a valid phone number.
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Phone Number
Please enter a valid phone number.
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

Powered by Jotform SignClear
Should be Empty:

Pathfinder Club Application Form

Image Release Form

Pathfinder Club Staff and Parent Volunteer Information

Parent and Volunteer Information

Health History

Education Record

Experience

Instruction Ability

Unlawful Conduct

References (for regular staff only)

Statement of Accuracy

Pathfinder Club Health Record