Indiana Conference Pathfinder Yearly Insurance Form

Indiana Conference Adventurer 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 $4.00 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 meetings located? *

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 *
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. They MUST be listed. *
Total Volunteers *
Please list ALL Adventurers participating in your club. *
Total Adventurers *
Total you owe for Insurance Premium? This form will automatically calculate for you.
There are three ways your clubs insurance fees?

1. Pay with www.adventistgiving.org (preferred) Choose: Indiana Conference Adventurers option

2. paypal Credit Card

3. Mailed Church Check to: P.O. Box 5000, Westfield, IN 46074 (Check must be RECEIVED by the deadline)

WHATEVER METHOD YOU CHOOSE, YOU HAVE TO HIT THE SUBMIT BUTTON BEFORE PAYING! IF YOU DON'T SUBMIT, YOU ARE NOT REGISTERED.
*

AdventistGiving.org (Prefered payment method) Choose Adventurers PayPal (use the PayPal option below) Church Check (please indicate Check number below)
PayPal Payment Option. ONLY use this if you are planning on paying with credit card.

USD Pathfinder Insurance Fees
Date you submitting this form *
Should be Empty:

Indiana Conference Adventurer Yearly Insurance Form