"*" indicates required fields1Team Member Information2Medical Release and Attendance Consent3Team Fee PaymentTeam Member InformationI am serving as a team member on:* Girl's BVN #31 Boys's BVN #31 Both Girl's BVN #31 & Boy's BVN #31I attended weekend:*Team Member Full Name* First Last Team Member Perferred NameBirth Date* MM slash DD slash YYYY Age*Please enter a number from 15 to 100.Gender*MaleFemaleT-shirt Size - You must still go to bvn shop webpage and purchase t-shirt*SmallMediumLargeX-LargeXX-LargeXXX-LargeThis item is so we can double check t-shirt orders if needed.Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone*Additional PhoneEmail* Team Member School or WorkTeam Member GradeTeam Member ChurchMedical Release and Attendance Consent Instructions: This form must be completed and appropriately signed by ALL WEEKEND PARTICIPANTS, and/or parent, or legal guardian of applicant prior to the commencement of the weekend activities. This completed form will be held by the Birmingham Vida Nueva Council representative (or designated party) during the course of the weekend.Name of Weekend Participant* First Last Weekend Participant is:* Under the age of 19 Over the age of 19Today's Date* MM slash DD slash YYYY Please indicate any and all medical allergies, medical problems or conditions, physical limitations (Asthma, diabetes, allergies, etc.), or any other pertinent information.*(Please print legibily, if necessary use additional space on back of this form)Please list all medications taken on a regular basis and/or brought with you to Vida Nueva. If you are on any current Prescription Medications and are under the age of 19, you must complete a Medication Form and turn it and all medications into the Weekend Nurse at send off.*(Prescription medications must have a pharmacy label)BVN does stock over the counter (OTC) medications for the weekend. If you give permission for the medical cha to provide OTC medication (i.e. Tylenol, Advil, Naproxen, Benadryl, Peto-Bismol) to your minor child, please check below. OTC medications are used to treat symptoms such as headaches, allergies or upset stomach.* Yes - I consent No- I do not consentParticipant's medical insurance company*Group #Policy #Insurance Company Phone #Family Physician Name*Family Physician Phone #*Father's (or legal Guardian) Name*Father's (or legal Guardian) Phone #*Mother's (or legal Guardian) Name*Mother's (or legal Guardian) Name Phone #*In the event of an emergency, I as parent, legal guardian, or myself (if 19 years or older) of above named candidate or participant, do hereby authorize an adult of Vida Nueva as agent for me, to consent to myself or minor child, receiving any X-ray, exam, medical, dental, or surgical diagnosis, treatment, and hospital care advised by a physician, surgeon, dentist, as appropriate, licensed to practice under the laws of the state where services are rendered, either at a doctor's office or in any hospital. I aurthorize the release of medical information to appropriate medical personnel and/or Health Insurance Company. I shall be obligated for all costs relative to any medical assistance and/or services rendered. In addition, I have, and do hereby, release Birmingham Vida Nueva, Inc., it's directors, or agents, from all liability associated with participation in Birmingham Vida Nueva.* Yes - I consent No - I do not consentIn checking below, I as a weekend participant, acknowledge that I understand that at no time are minors (ages 19 and younger) permitted to wander around the campground unsupervised. I agree to follow the schedule of the weekend, and stay within my assigned dorm once the team has been dismissed for the night. (This includes, but is not limited to, going into the lake, going to the outdoor activity areas, or walking the trails.) I understand that the result of not complying will result in being dismissed from the weekend and parents/legal guardians notified. Team fees will not be refunded.* Yes - I consent No - I do not consentSignature of Participant*Today's Date* MM slash DD slash YYYY Signature of Parent/Guardian unless Participant is over age 19.*Today's Date* MM slash DD slash YYYY Please choose one of the following to complete your form:* I will pay Team fee now I will pay fee at a later date I have already paid team feeName of Team Member* First Last Select Fee Payment Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
