San Diego Fil-AM Adventurer club 2026-2027
Staff registration
Full Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate if $20 payment was made; cash or check to San Diego Fil-AM (check memo: Adventurer registration)
*
Yes
No
Shirt size
Adult XS
Adult S
Adult M
Adult L
Adult XL
Approx date/year of AB506 (live scan for SECC conference specifically; put N/A if not yet completed)
*
Approx date/year of completing mandated reporting training for SECC conference specifically (put N/A if not yet completed)
*
Primary care doctor and phone number
*
Medical insurance plan number
*
Preferred hospital
*
Please list any food or medication allergies including reaction (ie: amoxicillin causes rash, peanuts cause hives)
*
Please list any prescription medications and what they are prescribed for. Please include medication strength and frequency
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Emergency Contact
*
First Name
Last Name
Relationship:
*
Phone Number
*
Format: (000) 000-0000.
Submit
Should be Empty: