APPLICATION FO MEMBERS IP

Date: Circle: Previous (PV, RB, SB) Leo Club

1, the undersigned, in good standing in my school and/or community, and in accordance with the
constitution and by laws of this club, hereby apply for membership in the
International Environmental Service Club

Name of candidate: (Legal /~_ _ _ _ _ _ _ _ _ (Nick

School
Date of Birth: Age: _ _ _ _ _ _ _ _ _ __
Parent or Guardian's
Address: __________________________________

City/State or province/postal ~~'~_. ___~ __________________________ ~_

Telephone:(HomeL _ _ _ _ _ _ _ _ _ _ _(Candidate

(Parent Cell) _ _ _ _ _ _ _ _ _ _ _ __

Candidate

Parent

I believe the above information to be true and complete, and I desire membership in this club. I
believe I can make a contribution to the club and be worthy ofthe friendship ofits members.

Signature o/applicant _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

To be completed by parent or guardian where parental permission is required by law for minors:

I hereby give my permission for my son/daughter to become a member ofthe above-named club.

INome & Signature ofParent or GuardiDn

-------------------------------
 CODE OF CONDUCT

I will do my best to positively contribute and keep a good standing

with the club.

I will conduct myself with mannerism & professionalism and show

respect to members, parents, leaders involved with club functions.

I will be on time for meetings, service projects and events.

I will be subject to termination from the club if I accrue more than 3

UNEXCUSED absences from all club functions. All absences will
need to be excused by the lEse president PRIOR to an event.

During the duration of a meeting, projects or events, I will keep my

cell phone on vibrate or turned off and refrain from using or texting
the phone or any other electronic devices. After 1st warning, I will be
subject to termination from the club.

I understand that I will be subject to termination from the club if any

disciplinary action is needed due to any inappropriate behavior.

I, (member name), have read the code of

conduct and will comply with the terms above.
 ;XI
--,

Ail 1~

xU 11=: ~ 1I1 ~~ kltll A Ed (International Environmental Service Club) 012.1- ~

Xi121=: tll~2.18X~IL~ JHeJ9.1 ~2.1 ~~O~ oDISfi 8X~IJ~ O~LlD.

Xi131=: J:<!-.2.1
~)jIOUkl AJtl ~ JD::I
~:::ClI 01 VD

.2.1 M 8 x~12~::: ~ Oi
gM8XlI~A-j ¥2
2~ JJL=lJ~ ~o~::: TI~~~O J ~ ;g 011 el o~.::i] 3 f! AIJIOli V::: 2l~\::!

011 Jil -2:l Oi ~.::i] Z:! ~ 2! (] Ed 01 ~!r ~ o~::: C·lI ~Ol VD.

X112~ :2.l~

Xi15~ .2.1~

AI2![~

Xi161=: .2.1~ 0119.11::l~ Jil ~§o~.::i] :2j~2!9.1

01 L~ ~¥2 ~2.I.::i] ~)jl

Xi171=: :2j~::: gjAI OIU gM~§ AI2!~ ~402!Cl-.

XiIS1=: :2j~ Ol~ !f!8 ~61o~t:! 9.1 A~2.:l~ A~§ ~~oHJ:j

8 M tll A ~ Ed 011 Jil e1 £1 Oi OF2! [f.

1I191=: :2j~::: El 01 CH 2.1 ~ g6:i o~Oj Mit 40Jf ~o[J:j Credit 2.! ~£I AI
Bt~[f.

Xi1101=: .2.1~2 Cellular phone. ipod ~::: ~AfJIJIU 2SJ"JIJI~ J~AI

J~AI.::i] 2~M OJ! M~ND ~)jIA~OlI oH ~~£It:! tl~~

o~Oj Cl-~ OH 01 AI * Vcl-.

Ai13~ .!F-~
Xii 1 01 L~
Xii 1 J:<!- ~El\1!jttl~~1 JH -0J1::l" ~~~ JH2.!~0IJlLf tllxLIA.~O~ M~of@!

.?f~~ * ~[f.

Print Member Name Member Signature Parent Signature

 Transportation Permission

I as parent ofthe student give permISSion

to be transported for volunteer program ofInternational Environinental Service Club for 2010.
Any of the HLC adult drivers has my permission to seek medical treatment for my kid
in case of illness, injury or accident.
Under no circumstances whatsoever will any member of our family hold liable or
make a claim against the International Environmental Service Club, leaders, or parents in the
club for any accidents or injury.
By signing below parents and guardians acknowledge they have read this notice and
accept responsibility.

I I
Parent's signature Student's signature Date

*Emergency Contact Information

Name Home phone Cell phone

*Health Insurance Information

Insurance r~rlru3r' Policy&Group #

Primary care physician; Telephone#

 Medical Release Form

Parent/Legal Guardian's
Address: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ .................. _­
Phone Numbers:
In an emergency, please ,",Vj'''''~ •.__ ........................ _____________________

Relationship to child/children:

Phone N"~t,pr's:. _ _ _ _ _ _ _ _ _ _ _ _ _........................_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

Physician's
Address:
Phone

Dentist's

Primary Insurance ComlJian:y:__________________ ........................_ _ _ __

Address:_ _ __ ______________~Phone: _ _ _ _ _ _ _ _ __
Policy Holder's

Relationship to
ID Number:_ _ _ _ _ _ _ _ _ _ _ _Group/Policy
Statement of Consent:

STATEMENT OF CONSENT

In the event of an emergency or non-emergency situation requiring medical treatment,

1_ _ _ _ _ _ _• hereby grant permission for any and all medical and/or dental attention to be
administered to my child/children. in the event of an accidental injury or illness, until such time as
1 can be contacted. This permission inc1uded. but is not limited to, the administration of first aid,
the use of an ambulance. and the administration of anesthesia and/or surgery, under the
recommendation of qualIfied medical personnel.
1 also acknowledge thtlt International Environmental Service Club is not responsible for any
accident or injuries that can occur in the event of Intemational Environmental Service Club's
activj{ies.

Signature:___........... __________________~

 T-shirt & Hood T-shirt Order Form

T-shirt Total # of T-shirts Totals

m xl ,@$ =

Hood T-shirt Total # of Hood T-shirts Totals

m @$ =

Subtotal =

I Grand Total

Your Name:

Address:

City, State, Zip:

#AIA~~~ .!:2. LH ~ email address: