St. George Pathfinders Druzhina NN

St. George Pathfinders, Inc. - Western American Region

Druzhina Nizhni Novgorod Child 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!
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, Inc. - Western American Region