Membership Form

**each item must be completed**

If you are registering more than one daughter, please submit separate forms for each.

Daughter's Name:
Date of Birth: 
School:   Grade on 9/2018: 
Mother's Name:
Father's Name:
Street Address:
City:     Zip: 
Home Phone:
Daughter's Cell:
Mother's Cell: 
Daughter's Email:
Mother's Email:
 
MEDICAL CONSENT: 
Medical Insurance: 
Policy #: 
Physician's Name: 
Physician's Phone: 
Dental Insurance: 
Policy #: 
Dentist's Name:
Dentist's Phone:
Date of Last Tetanus Shot:    
Date of Last TB Test:

Alternate
Emergency Contact (other than parents):
 
 
Phone: 
Any allergies/medical conditions::

Please accept this as permission for my daughter to participate in all activities by Ek Kardia, Inc. during the period of June 1, 2019 to May 31, 2020. As part of these activities, she has my permission to travel with the ass6gned adult driver. I hereby authorize an adult officer and/or the assigned adult in charge to arrange all necessary emergency medical treatment that my daughter may require while under the supervision of the adults in charge in the event the undersigned is unable to consent to this emergency treatment. The undersigned hereby agrees to indemnify and hold Ek Kardia, Inc. harmless from the acts of the above-named while participating in the meetings and activities of Ek Kardia, Inc.

I understand that to be a member in good standing of Ek Kardia, Inc. I must abide by the requirements set for membership. I also agree to complete a minimum of four service projects and for mothers to "lead" one service project prior to May 31st each year.

BY SUBMITTING THIS FORM, YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS OF EK KARDIA MEMBERSHIP.

(Upon submission you will be taken to Step 2 of 3: Ek Kardia Release Agreement)