Team Member Forms 1 Team Member Information2 Medical Release and Attendance Consent3 Team Fee Payment Team Member InformationI am serving as a team member on:* Girl's BVN #27 Boys's BVN #27 Both Girl's BVN #27 & Boy's BVN #27 Team Member Full Name* First Last Team Member Perferred NameBirth Date* Date Format: 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 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* Date Format: 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 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. 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* Date Format: MM slash DD slash YYYY 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 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Cardholder Phone number*PhoneThis field is for validation purposes and should be left unchanged.
