Team Member Forms 1 Team Member Information2 Medical Release and Attendance Consent3 Background Check Form4 Team Fee Payment Team Member InformationI am serving as a team member on:* Girl's BVN #25 Boys's BVN #25 Both Girl's BVN #25 & Boy's BVN #25 Team Member Full Name* First Last Team Member Perferred NameBirth Date* Age*Please enter a value between 15 and 100.Gender*MaleFemaleT-shirt Size*SmallMediumLargeX-LargeXX-LargeXXX-LargeAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mobile Phone*Additional PhoneEmail* Team Member School or WorkTeam Member GradeTeam Member Church Medical Release and Attendance Consent Instructions: This form must be completed and appropriately signed by ALL WEEKEND PARTICIPANTS, and/or parent, or legal guadian of applicant prior to the commencement of the weekend activitities. 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 19Over the age of 19Today's Date* 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 consentNo- 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 consentNo - 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, hiking to the cross, 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 consentNo - I do not consentSignature of ParticipantSignature of Parent/Guardian unless Participant is over age 19. Background Check Concent Form: I certify and declare under penalty of perjury under relevant state and federal law that the information contained in my application is complete, true, and accurate. I acknowledge that falsification or omission of information may result in immediate dismissal or retraction of any offer of residence. In consideration of Birmingham Vida Nueva (BVN)'s review of my application, I herby voluntarily consent to and authorize BVN, or its authorized agents bearing this release or copy thereof, to obtain a consumer report. I agree that this consumer report may include any of the following. * Employment Verification, Education Verification, Credentials Verification, Personal Identity Verification, Past Employment Verification, Reference Checks, Criminal Records, Civil Cases, Motor Vehicle Records, Credit Report. I authorize all persons and organizations that may have information relevant to this research to disclose such information to BVN or its authorized agents. I hereby release BVN, its authorized agents, and all persons and organizations providing information from all claims and liabilities of any nature in connection with this research. I hereby further authorize that a photocopy of this authorization may be considered as valid as the original. I understand that I have specific prescribed rights as a consumer under the federal Fair Credit Reporting Act (FCRA), and may have additional rights under relevant state law. I hereby certify that I have been informed of my rights.Signature of Applicant*Today's Date* Social Security Number*Full Name*Maiden Name(s)Date of Birth*Driver's License Number*State of Issue*Current Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EMPLOYER TO CHECK SERVICES TO BE COMPLETED: _ALABAMA STATEWIDE CRIMINAL _PEER CREDIT REPORT; _STATEWIDE CRIMINAL _PREVIOUS EMPLOYMENT VERIFICATION; _COUNTY CRIMINAL _REFERENCE VERIFICATION _SOCIAL SECURITY TRACE _WORKER'S COMP; _MOTOR VEHICLE REPORT _EDUCATION VERIFICATION; _SEXUAL OFFENDER REGISTRY _OIG EXCLUSIONSSTATE(S)________________ COUNTY_________________ ***NOTE:FOR EDUCATION AND EMPLOYMENT VERIFICATION PLEASE SUPPLY ADDITIONAL INFORMATION (RESUME OR APPLICATION) **INFORMATION IS BEING VERIFIED BY QUALITY COUNTS, INC. ANY INFORMATION OR QUESTIONS SHOULD BE DIRECTED TO THE FOLLOWING ADDRESS: QUALITY COUNTS, INC. PHONE:205-561-2340 FAX:205-561-2344 OR 877-349-1990 Please choose one of the following to complete your form:*I will pay Team fee nowI will pay fee at a later dateI will pay team fee in BVN shopI have already paid team feeName of Team Member* First Last Select Fee Payment Date* Team Fee*Please select one of the choices below. Team Full FeePartial Team Fee PaymentPartial Team Fee Payment Amount: Total Fee Paid $0.00 Debit or Credit Card Payments* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Cardholder Phone number*NameThis field is for validation purposes and should be left unchanged.
