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Microsoft word - yc'13 registration form individual

Wednesday, July 31 – Saturday, August 3, 2013: YMCA of the Rockies This convention participant has/or is subject to: (Please check appropriate box(es)and briefly describe the condition, severity, and treatment of each. Attach separate sheet if necessary.) ___ Youth Convention Staff Member ___ Pastor Please Print
________________________________________________ Name_______________________________________________ Male Female (please circle) Does convention participant carry an EpiPen or anaphylaxis kit? Yes or No\ Address______________________________________________________________________ Reason____________________________________________________________________ City, State/Prov., Zip/Postal Code_________________________________________________ Is convention participant able to receive Benadryl in the event of an emergency? Yes or No Have they taken Benadryl before? Yes or No Phone (____)_____________Email Address________________________________________ Please List all Medications Taken Regularly and for what reason: High School Grad Year_________________ Birthdate (mm/dd/yyyy) ____/____/_____ ___________________________________________________ Home Church __________________________________________T-shirt Size S M L XL XXL ___________________________________________________ ___________________________________________________ Emergency Contact

Name________________________________Relation__________________________________
___________________________________________________ ___________________________________________________ Home Phone_______________________Other Phone__________________________________ Name_______________________________Relation___________________________________ ___________________________________________________ Home Phone________________________Other Phone_________________________________ Health Insurance Information
Date of Last Tetanus Immunization_____________________________________________ Date of Last Physical Exam_____________Any significant changes?__________________ Name of Insurance Company______________________________________________________ Policy number(s)________________________________________________________________ Medical/Liability Release (Must be signed by parent for those under 18)
Name on Insurance Policy________________________________________________________ I, ____________________(or the parent/legal guardian of ______________________) authorize and consent to medical, surgical, and hospital care, treatment, and procedures to be performed on myself (or Convention Covenant
my child) by a nearby medical facility as church staff and/or Lutheran Brethren Youth Convention staff deem necessary. I also understand that, if applicable, I (or my child) will be self-administering my (his/her) It is my intention to attend the 2013 National Lutheran Brethren Youth Convention. I agree to take part in all own documented medications during the convention under the orders of a personal doctor. I also give activities relating to this convention in a positive and responsible manner, for my own benefit and as an permission for a registered nurse to make available, under observation, Tylenol and ibuprofen to myself example to others. I will respect any and all rules of conduct given by the convention staff and the leaders of (or my child) should I (he/she) need it. my church group, including travel to and from the convention site. I will value the property of the park and use all facilities responsibly and within guidelines both published and implied. I understand that use of Signature of Participant_______________________________________________Date_____________ tobacco products, alcoholic beverages, fireworks, and illicit drugs is prohibited and such use is grounds for dismissal from the convention with travel home at my expense or the expense of my parents. Signature of Participant____________________________________________Date___________ Liability Waiver

I, the parent, hereby acknowledge that I have voluntarily allowed my child
listed above, to participate in the YC13 retreat, held at YMCA of the
Rockies, Estes Park, CO. I understand that participation at this retreat may
present hazards and exposures to risk or harm. I am aware of the risks
inherent to this activity and I knowingly and willingly allow my child,
listed above, to assume the risk of injury, including what might result from
loss of control, collisions with other participants, and other obstacles,
whether obvious or not obvious. I understand that any bodily injury, death,
or loss of personal property and expenses as a result of these activities is
my responsibility. As lawful consideration for my child being permitted to
participate in this activity, I release from any legal liability, YC13 officers
and leadership, the Church of the Lutheran Brethren, YMCA of the
Rockies and any individual or agency whose property and scheduled
activity may be required to be utilized in the activities provided
I further agree not to sue, claim against, attach the property of, or prosecute
YC13 officers and leadership, the Church of the Lutheran Brethren and
YMCA of the Rockies and any of their officers, members, affiliate
organizations, agents and employees for any injury or death caused by
participation in this activity. I agree to defend, indemnify and hold
harmless YC13, Church of the Lutheran Brethren and YMCA of the
Rockies and all their officers, members, affiliate organizations agents and
employees for any injury or death caused by or resulting from my child’s
participation in this activity.
This contract shall be legally binding on me, my estate, heirs, assigns, legal
guardians, and personal representatives. I have carefully read the above
and fully understand its contents. I am aware that I am releasing certain
legal rights and I may have, and I enter into this contract with my own free
will.
Parental/Guardian signature______________________________________
If you wish to not permit the intentional use of photographic images of
your child, please sign and date the line blow
____________________________________________________________

Source: http://clbnetwork.org/wp-content/uploads/2012/08/yc13-individual-registration.pdf

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