Event Permission and Release Form
YEC 2018 Participant and Chaperone Form January 12-13, 2018
Email address *
Participants full name: *
Your answer
Mailing Address: *
Your answer
City, State & Zip: *
Your answer
Date of Birth: *
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DD
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YYYY
Home Phone: *
Your answer
Participants Cell Phone:
Your answer
Parents Cell Phone:
Your answer
Emergency Contact #1 Name and Phone Number *
Your answer
Emergency Contact #2 Name and Phone Number *
Your answer
Date of last tetanus shot:
MM
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DD
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YYYY
Allergies (both medical & food) *
Your answer
Medications to be taken and Dosage: *
Your answer
Family Physician: (Name and Phone Number) *
Your answer
Family Dentist: (Name and Phone Number) *
Your answer
Name of Insurance Company: *
Your answer
Insurance Company Address and Phone Number *
Your answer
Insurance Policy Number: *
Your answer
Name of Policy Holder: *
Your answer
Do leaders of Old Fields Baptist Church have permission to transport your child on this youth event? *
Do leaders of Old Fields Baptist Church have permission to take care of minor cuts, scrapes, stings, etc.? *
Do leaders of Old Fields Baptist Church have permission to administer Tylenol or Ibuprofen in case of a headache? *
For participants under 18 years of age I understand that in the event of an emergency, reasonable effort to contact me will be made. However, if I am unable to be contacted, I authorize Old Fields Baptist Church Leaders to act on my behalf until contact can be made.
Pastor Nathan will have you sign this before departure.
Your answer
For other participants - In the event that I am unable to make medical decisions for myself, I give permission to Old Fields Baptist Church Leaders to act on my behalf until emergency contacts are notified.
Pastor Nathan will have you sign this before departure.
Your answer
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