Birmingham Vida Nueva
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"*" indicates required fields

1Team Member Information
2Medical Release and Attendance Consent
3Team Fee Payment

Team Member Information

I am serving as a team member on:*
Team Member Full Name*
MM slash DD slash YYYY
Please enter a number from 15 to 100.
This item is so we can double check t-shirt orders if needed.
Address*
Medical 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*
Weekend Participant is:*
MM slash DD slash YYYY
(Please print legibily, if necessary use additional space on back of this form)
(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.*
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.*
In 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.*
MM slash DD slash YYYY
MM slash DD slash YYYY
Please choose one of the following to complete your form:*
Name of Team Member*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

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