Capital City Adventurer Club Registration Form

Capital City Satellites Adventurer Club Registration & Health Form

Completion of this form is mandatory for all Adventurers interested in joining the club for the upcoming year. Please ensure that you fill out the form in its entirety, and remember to click the "Submit" button when you have finished. We kindly request information from both the Adventurer and their Parents/Guardians.
Child's First Name*
Child's Last Name*
Birth Date:*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Parent/Guardian's E-mail*
School*
Current Grade in School*
T-Shirt Size*
Pledge
Because Jesus loves me, I will always do my best.

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.
Applicant Class Information (Class invested in):*

New to ClubLittle LambEager BeaverBusy BeeSunbeamBuilder
I, the Adventurer whose name is mentioned above, am eager to become a member of the Capital City Satellites Adventurer Club. I commit to participating actively in club meetings, engaging in various activities and field trips, and fully embracing all club-related events. With pride, I pledge to wear my Adventurer uniform as a symbol of my dedication and will faithfully adhere to the club's guidelines. In my interactions with others, I will strive to embody the qualities of cheerfulness, helpfulness, honesty, kindness, and courtesy.
Signature*

Clear
Parent/Guardian Information

In order to make sure that every family is included in club communications, we require the email address and cell phone number of at least one parent/guardian.
Father/Guardian

First NameLast Name
Email (example@example.com)
Mother/Guardian

First NameLast Name
Email (example@example.com)
We will need multiple ways to contact you about club announcements and events. WhatApp will be the primary method for sharing of detailed information, but what other methods would you be willing to use?

Text
Consent of Parent/Guardian
As parent/guardian, we understand that the Adventurer program is an active one that includes many opportunities
for service, adventure, fun, 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.
Medical History and Information
I have read, understood, and accepted the membership pledge.
Signature*

Clear
Date*

MonthDayYear
Food Allergies*
write none if you have no allergies
List of any restrictions
Current Medication and/or additional information.
Primary Physician*
Insurance Company
Policy Number
Phone Number
Emergency Contact*
Phone Number*
Authorization to Treat a Minor

I, the parent, parents, or legal guardian of the Adventurer named above, hereby grant permission for emergency medical care in case of need. I authorize the club officials to select a physician to hospitalize, provide necessary treatment, and administer injections, anesthesia, or surgery as required for my child.

As the parent or legal guardian of the applicant, I support their attendance at club functions and accept the associated terms and conditions. The provided health history is accurate to the best of my knowledge, and I grant permission for the described individual to participate in all planned club activities unless otherwise specified. Additionally, I have read and comprehended the Emergency Authorization statement and consent to its terms without reservation. I also approve the photocopying of this health record when necessary.
Parent/Guardian Signature*

Clear
Date*

DayMonthYear
Pickup Authorization
Please list person(s) authorized to pick up your child from Adventurer functions*
Parents/Guardians your child will be released from Adventurer functions only to persons listed above. If other arrangements are necessary, a note must accompany your child and a call must be made to the Club Director/Associate Director prior to the Adventurer function. No exceptions! Thank you for your cooperation.
Adventurer Dues
The registration fees for the upcoming 2023-2024 Adventurer year will remain consistent with last year's rates. The fees are as follows: $104 for new Adventurers and $80 for returning Adventurers. These registration fees are inclusive of various essential items, such as uniform accessories, award patches, the activity workbook, a class "B" uniform t-shirt, and necessary materials and supplies for class activities.

To provide flexibility in payment, you have the option to either pay the full amount as a lump sum of $104 for new Adventurers or $80 for returning Adventurers. Alternatively, you can choose to split the payment into four (4) monthly installments of $26 for new Adventurers or $20 for returning Adventurers, with payments due in October, November, December, and January.

To remit these dues, please utilize one of the following methods:
1. CashApp: You can make a payment through CashApp by visiting http://cash.app/$capcitysdac.
2. AdventGiving: Alternatively, you may use AdventGiving at https://adventistgiving.org/donate/AN4FE6. Please click on the "more offering" category and select "Adventurer Club" to make your payment.
3. In-Person Submission: If you prefer a physical submission, kindly place your payment in a tithe envelope with your Adventurer's name clearly written on the envelope. You can then remit the envelope during the tithe and offering collection.
Should be Empty:

Capital City Satellites Adventurer Club Registration & Health Form

Parent/Guardian Information

Consent of Parent/Guardian

Medical History and Information

Pickup Authorization

Adventurer Dues