St. George Pathfinders Druzhina Kiev

St. George Pathfinders Western American Region

Druzhina Kiev Child Membership Form
Годовые Членские Взносы 2025 / Annual Dues 2025
- $100 каждый член / $80 Скауты пенсионного возраста
- $100 per individual member / $80 special pricing per individual retiree
To be fully registered, complete both steps by March 31, 2025:
1. Fill out, sign and submit your membership form/s. You'll receive a completed copy of the form in your email.
2. Submit payment.
Important Reminders:
1. Volunteer time per family is 20 hours. These hours can be accomplished by helping out at our fundraisers, working on special projects, and helping out on work weekends or camp.
2. You must notify us if any of your information changes during the year.
Payment Information:
1. Payments via Zelle may be made to: kievdruzhina@gmail.com
2. Payments via credit card may be made online.
3. Make checks payable to “St. George Pathfinders” and send to: St. George Pathfinders, c/o Ann Kutner, 2970 22nd Avenue, San Francisco, CA 94132
Spasibo! Thank you for supporting our scouting organization!
Child's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Parent/Guardian Name:*

First NameLast Name
Relationship:*

ParentGuardianOther
Parent/Guardian Email 1:*
Alternate Email 2:
Phone Number 1:*

Area CodePhone Number
Alternate Phone Number:

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Member's cell for chat/group text (optional):

Area CodePhone Number
Name of medical insurance company for above named child:*
Policy number:*
Child is known to be allergic to the following foods and medications. Additionally, special attention should be paid to the following medical problem: (e.g. other allergies, fainting, diabetes, heart disease, enuresis (bed-wetting), epilepsy, etc.):*
Enter N/A if the child has no allergies.
Tetanus shot in effect:*

MonthDayYear
Date
PARENTAL RELEASE & CONSENT FOR MEDICAL AND SURGICAL CARE FORM

I/We hereby give consent for Child’s Name: {childsName} Date of Birth: {dateOf} to participate in all 2025/2026 activities including, but not limited to Summer Camp conducted by the St. George Pathfinders and travel by bus, private auto or other type of vehicle with the St. George Pathfinders.

I/We agree to direct our child to cooperate and conform to directions and instructions of the supervisory personnel in charge of the program. Furthermore, the undersigned agrees to hold the St. George Pathfinders, their officers and all individuals (volunteer adults or other scout campers) placed in charge harmless of any claims that may arise against them from bodily injury or property damage due to accidents or occurrences arising out of my/our child's participation and/or travel in the course of said program whether the result of negligence or any other cause.

Use or possession of alcohol, drugs or smoking material during the Camp sessions on or off the Camp premises will lead to automatic expulsion from the Camp. Rules for acceptance and participation in the program are the same for everyone without regard to race, color, or national origin.

By signing below, I/we hereby give permission for child named above to receive from camp staff over-the-counter medications (i.e., aspirin, Tylenol, topical ointment, etc.) and/or medical or surgical treatment and to be hospitalized if necessary in case of injury or possible illness while participating in a program and/or traveling with the St. George Pathfinders.

By submitting my membership registration / or as parent or guardian of my child, I acknowledge the use of photographs/media taken during events or activities for publicity, promotional and/or educational purposes (including publications, presentation or broadcast via newspaper, internet or other media sources).

It is further recognized and agreed that the St. George Pathfinders, their officers and individuals placed in charge will not be liable in any way for accidents, injury or other mishaps whether the result of negligence or other cause.

IT IS UNDERSTOOD THAT IN CASE OF EMERGENCY EVERY EFFORT WILL BE MADE TO CONTACT US OR THE PERSON LISTED IN THE FORM.

SIGNATURE SIGNIFIES CONSENT/AUTHORIZATION THROUGH 3/31/2026 UNLESS OTHERWISE SPECIFIED. TO BE SIGNED BY PARENT OR GUARDIAN.
Signature of Legal Parent or Guardian:*

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Date of Signature:*

MonthDayYear
Child's Photo:*

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Front side of child's medical insurance card:*

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Back side of child's medical insurance card:*

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St. George Pathfinders Western American Region