Indiana Conference Pathfinder Yearly Insurance Form

Indiana Conference Pathfinder 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.

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

First Name Last 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

City State / Province

Postal / Zip Code
Director's Mobile Number *

Area Code Phone Number
Choose your Pastor *
Pastor Not listed?

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

First Name Last 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 2. Mailed to: P.O. Box 5000, Westfield, IN 46074 3. Credit Card. *

Adventistgiving.org (preferred method) PayPal (use the PayPal option below) Church Check (please indicate Check number below)
Date you submitting this form *
Should be Empty: