Indiana Conference Pathfinder Yearly Insurance Form

Master Guide Club Yearly Insurance Form

DEADLINE: OCTOBER 1
The Indiana Conference purchases liability and medical coverage for our pathfinder clubs. The medical coverage is for $5000 primary, if the activity is on our premises or $5000 excess, if an accident occurs during a sponsored activity off premises.

Your cost is $5.00 per pathfinder or adult leader.
Church sponsoring this club?
Director's Name

First NameLast Name
Director's E-mail
you will receive an email of this submission
Where are your Pathfinder Club meetings located?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Director's Mobile Number

Area CodePhone Number
Choose your Pastor
Pastor Not listed?

First NameLast Name
Church Pastor's Email
If you would like to receive a copy of this form.
Pastor's Initials
Treasurer's name

First NameLast Name
Church Treasurer's Email
If you would like to receive a copy of this form.
Treasurer's Initials
Please list ALL volunteers participating in your club.
Total Volunteers
Please list ALL Volunteers participating in your club. They MUST be listed.
Please list ALL Pathfinders participating in your club.
Total Pathfinders
Total you owe for Insurance Premium? This form will automatically calculate for you.
How are you planning on paying your clubs insurance fees? 1. Adventistgiving.org (online digital) 2. Mailed to: P.O. Box 5000, Westfield, IN 46074

Other
Date you submitting this form
Should be Empty:

Master Guide Club Yearly Insurance Form