Personal and Family Information Name Birth date Address Afghanistan Albania Algeria Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Terr. Bonaire (Dutch Caribbean) Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, Democratic Republic of Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Terr. Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Isl. & Mcdonald Isl. Vatican City State Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, D P R Korea, Republic of Kuwait Kyrgyzstan Lao People's D R Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, Former Y R of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, O Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent & Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia & S S Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States M O Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Home phone Cell phone Email Church Adventurer Club Name of spouse (if applicable) Children: Name - Birth date: Month - Day - Year Health History Do you have any injury/sickness that might limit your involvement in Pathfinder Club activities? If yes, how would it hinder? Yes/No Yes No Education Record Highest degree/diploma held Year degree/diploma received School granting degree/diploma College major/minor Experience List all experience working with children (Adventurers, Scouts, Sabbath School, etc.) Position / type of work / Church / organization / Date of service Pathfinder Club Staff and Parent Volunteer Information Have you been accused, charged, or disciplined for any unlawful sexual conduct, child abuse, and/or child sexual abuse? Yes/No Yes No If yes, please complete the information below. Date/place Type of conduct Reference name, address, and phone Background Check I will complete the background screening and training required by our conference. References (for staff only) List three individuals who know you well enough to recommend you as an Pathfinder staff member. Please include name, address and phone number. References Statement of Accuracy The above information is accurate to the best of my recollection. I understand this is strictly a volunteer position, and I will receive no remuneration for services and time volunteered. Signature Date Submit