St. George Pathfinders Druzhina NN

St. George Pathfinders, Inc. - Western American Region

Druzhina Nizhni Novgorod Adult Membership Form
ANNUAL DUES 2025 / ГОДОВЫЕ ЧЛЕНСКИЕ ВЗНОСЫ 2025

$100 каждый член / per individual member
$80 Скауты пенционного возраста / special pricing per individual retiree

To be fully registered, you must complete all items by March 31, 2025:
1. Fill out, sign, and submit your membership form(s) online. You'll receive a completed copy of the form in your email. *Please note, paper/PDF forms may still be submitted to the address listed below.
2. Submit payment (late fees may apply to renewing members who do not pay by the deadline)
Payment Information:
1. Payments via Zelle may be made to: razvedchik.dnn@gmail.com
2. Payments via Square may be made to: https://razvedchik.square.site/
3. Make checks payable to “St. George Pathfinders” and send to:
St. George Pathfinders
c/o Zoya Lechtholz
3916 Berryman Ave.
Los Angeles, CA 90066

✉: zaychik428@gmail.com
📞: 401.952.6030

You must notify us if any of your information changes during the year.

Spasibo! Thank you for supporting our scouting organization!
Member's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number 1:*

Area CodePhone Number
Phone Number 2:

Area CodePhone Number
Email:*
example@example.com
Member's cell for chat/group text (optional):

Area CodePhone Number
Emergency Contact:*

First NameLast Name
Relationship:*

SpouseParentChildOther
Emergency Phone Number 1:*

Area CodePhone Number
Emergency Alternate Phone Number:

Area CodePhone Number
Name of medical insurance company for person signing this form:*
Policy number:*
I am 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, epilepsy, etc.):*
Enter N/A if you have no allergies.
ADULT CONSENT FOR MEDICAL AND SURGICAL CARE FORM

I ({membersName}) hereby give my consent to receive medical or surgical treatment and to be hospitalized if necessary in case of injury or possible sickness while participating in the 2025/2026 program and/or traveling with the St. George Pathfinders.

It is agreed that in the event of sickness, injury or accident I will assume full financial responsibility for the payment of medical and/or other costs.

It is further recognized and agreed that 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.

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 understood that in case of emergency every effort will be made to contact the emergency contact provided.

SIGNATURE SIGNIFIES CONSENT/AUTHORIZATION THROUGH 3/31/2026 UNLESS OTHERWISE SPECIFIED.
Signature:*

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Date of Signature:*

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St. George Pathfinders, Inc. - Western American Region