Registration Form
(copy as needed)
The weekend is $100. Registration will be cut off on September 24, or at capacity. Adult Advisors Please send a list of the youth for whom you will be responsible at this event
Name
Address
City/State/Zip
Email
Grade 8__Gender ___________ T-shirt size small__ medium__ large__
Church name and Location __________________________________________
Name of accompanying Adult(s) ___________________________________
Any special physical or dietary needs __________________________________
________________________________________________________________
Make check payable to the Diocese of Virginia. Enclose a $40 deposit per participant and mail to the Program Office, Diocese of Virginia,
I hereby give my permission for my child to attend diocesan Parish Youth Ministries event eight grade weekend, September 28-30, 2007.In the event of an accident or illness, to receive emergency medical treatment as deemed necessary by a licensed physician. This permission shall remain in effect from September 2007-May 2008.
Furthermore I give permission to the Diocese of Virginia to use the above named child’s likeness participating in this program in perpetuity in any format, including but not limited to web based publications, The Virginia Episcopalian, and PYM flyers.
HEALTH HISTORY
Date of last Tetanus Booster _______________________________________________
Please list any current medications, pertinent medical conditions, allergies, physical limitations, dietary or health requirements, etc. ___________________________________________________________________________________________
INSURANCE INFORMATION
Name of Medical Insurance Company ________________________________________
Name of Insured __________________________________________________________
Policy Number ______________________ Phone number ________________________(for authorization)
RELEASE FOR MEDICAL TREATMENT
______________________________, my daughter / son has my permission to attend this Parish Youth Ministries Events. If I cannot be reached by telephone in case of emergency, I authorize such medical treatment as necessary and such additional procedures as are considered necessary during the course of medical examination. I hereby certify that I have read and fully understand the above authorization for medical treatment. I also certify that no guarantee or assurance has been made as to the results that may be obtained.
Participant’s Signature _______________________________________________ Date ______________
Parent / Guardian Signature ___________________________________________Date_______________
Parent/Guardian Phone_____________________________(day)_________________________(evening)
Parent/Guardian Cell Phone ___________________________________________________________
Other emergency contact name _________________________________________________________
Emergency contact’s phone number ______________________________________________________
