Adventurer Club Application Form

SHOOTING STARS

Adventurer Club
Registration Fee: $5.00 Class A Uniform/Patches: $50*

*If financial assistance is needed, please contace your club director
Adventurer Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Age*
School *
Grade*
Church*
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Emergency Contact Name and Relation*
Emergency Phone*
Please enter a valid phone number.
Check Class(s) you have been invested in:*

Little LambEager BeaverBusy BeeSunbeamBuilderHelping HandAdvanced Helping Hand
I (Name of Applicant)*
I want to join the Shooting Stars Adventurer Club. I will attend meetings, activities, field trips, and other club activities. I will proudly wear my Adventurer uniform and obey club guidelines. I will be cheerful, helpful, honest, kind and courteous. Signature of Adventurer*

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Approval/Consent of Parent/Guardian

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

1.Encouraging my Adventurer to take an active part in all club meetings and functions.

2.Attending events to which parents are invited in support of my Adventurer.

3.Assisting club leaders by serving as a helper when needed.

4. Not holding any individual club staff member liable in the event of an accidental injury.

5.Giving my permission for the above-named Adventurer to attend Adventurer activities.
Signature*

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Print Name*

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.
Dated

MonthDayYear
Date
Print Name
Signature

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Address

Street Address

Street Address Line 2

CityState / Province

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

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Adventurer 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 Date

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 of Spouse (If Applicable)
Birth date of spouse

MonthDayYear
Date
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
Degree/diploma received
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

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Date

MonthDayYear
Date

Adventurer Club Health Record
Name of Adventurer

First NameLast Name
Birth Date

MonthDayYear
Date
Age
Grade
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Social Security Number (last 4 digits)
Date of Last Tetanus Booster

MonthDayYear
Date
Allergies to drugs or foods:
List any restrictions
Telephone Numbers Where Parents May Be Reached:
Father:
Name

First NameLast Name
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Mother
Name

First NameLast Name
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Emergency Contact Name and Number
Family Physician Name and Number
Family (or Pediatrician) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company and Policy number
Authorization to Treat a Minor
I (we) the undersigned parent/parents or legal guardian of Name of Adventurer
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

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Date

MonthDayYear
Date
Should be Empty:

SHOOTING STARS

Image Release Form

Adventurer 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

Adventurer Club Health Record

Telephone Numbers Where Parents May Be Reached:

Father:

Mother

Authorization to Treat a Minor