Chapel Oaks Adventure Club

Mighty Acorn Registration Form

Please fill in the form below.
Full Name*

First NameLast Name
Birth Date

MonthDayYear
Age
Grade
Parent(s) Name(s)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Emergency Phone Number

Area CodePhone Number
E-mail*
E-mail
I, ________________________, want to join the Chapel Oaks Adventurer Club. I will attend meetings, field trips, and other club activities. I will proudly wear my Adventurer uniform and obey club guidelines. I will be cheerful, helpful, honest, kind, and courteous.
Adventurer Member Signature
Check class(es) in which you have been invested

Little LambsEager BeaversBusy BeeSunbeamBuilderHelping Hand
Approval/Consent of Parent/Guardia

As parent/guardian, I understand that the Adventurer program is an active one which includes many opportunities for service, adventure, fun, and learning. I will support the program by:
1. Encouraging my Adventurer to take 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 permission for the above-named Adventurer to attend Adventurer activities.
Parent/Guardian Signature
Adventurer Club Health Record
Name

First NameLast Name
Birth Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Please list allergies to foods and drugs, special medications, or pertinent information/restrictions
Emergency Contact Information
Father Name

First NameLast Name
Phone Number

Area CodePhone Number
Mother Name

First NameLast Name
Phone Number

Area CodePhone Number
Name

First NameLast Name
Phone Number

Area CodePhone Number
Family Physician

First NameLast Name
Physician Phone Number

Area CodePhone Number
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Company
Policy
Authorization to Treat a Minor

I (we) the Undersigned parent, parents or legal guardian of:_________________

In case of emergency, I herby give permission to the physician selected by the club directors to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child.

As parent or legal guardian of the applicant, I am in favor of him/her attending club functions and accept the conditions named. The health history stated is correct so far as I know, and the person herein described has permission to engage in all prescribed club activities except as noted. In addition I have read and understand the Emergency Authorization statement and give my full constent to the terms found therein. Permission for photocopying of the health record is granted.
Parent/Guardian Signature
Date

MonthDayYear
Should be Empty:

Mighty Acorn Registration Form

Adventurer Club Health Record

Emergency Contact Information