CLUBEDELDERESAZIMUTE

FichadeInscrio
Nome:___________________________________________________________________________
Endero___________________________________________________________n________________
Bairro:___________________________________________
CEP:______________________
Cidade______________________________________________________
UF:_____________
Fone(s):________________________________________ Sexo: M ( ) F ( ) Data
Nascimento:______________ Data de Batismo: _____/_____/____RG:___________________
RGOEMISSOR:_______CPF:_____________________________
Informaesparausomdico
1. TipoSanguneo/FatorRH:__________
2. Vacinaocontrattano:Sim()Data:________________No()
3. Sofrode:Diabetes()Epilepsia()Corao()Hemofilia()Bronquite()
Outros():________________________________________________________________
4. Soualrgicoa:Penicilina()Sulfa()Soro()Antitoxinas()
Outros():________________________________________________________________
Emcasodeemergnciasavisara:
Nome:__________________________________________Parentesco:____________________
Endereo:_____________________________________________________________________
Fone(s):_______________________________________________________________________
Email:______________________________________________________________________________
Gerais:
Clubeaquepertence:_________________________________Regio:________Campo:_________
Distrito:____________________Cargoatual:__________________________________________
Cargosquejocupou:_____________________________________________________________
Datadeadmissoemleno:_______________Datadeinvestiduraemlder:__________________
...emMster:____________________...emMsterAvanado:______________________
Nmerodeespecialidades:____________Mestrados:_______________
ltimaClasseInvestida:_____________________________________Nopossuoclasse:()
PorquefazerpartedoClubedeLderes:_________________________________________________
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ComosoubedarealizaodesteClube:___________________________________________________
reademaiorinteresse:HabilidadesDomsticas()ArteseHabilidadesManuais()Atividades
Agrcolas()AtividadesMissionrias()CinciaeSade()EstudodaNatureza()Atividades
Profissionais()AtividadesRecreativas()EspecialidadesRegionais().
GostariadecontribuirparaoClubedeLderesem:_________________________________________
__________________________________________________________________________________
Observaes:_______________________________________________________________________
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Assinatura: