B/N TEC Team Application (Adult)
Welcome to Bloomington/Normal Teens Encounter Christ on-line registration!

Completion of this form is required by ALL adult team members. It is used to provide general information; primary and secondary points of contact; general medical health information; and a standard authorization for emergency medical treatment (which would only be used in the UNLIKELY case of a medical emergency in which you are not able to respond, and your emergency contacts cannot be reached).

It is also used to determine if ADULT volunteers are in compliance with Catholic Diocese of Peoria policy regarding participation in Diocesan-sponsored activities involving minor children. We also ask that TEC team members, pay $75.00 to help offset food costs for the upcoming weekend. You can give a check or make payments to your board advisor during team preparation.

First, MI, Last
Your answer
TEC Team Number *
Your answer
What position have you agreed to fill *
YOUR Mailing Address *
(number) (street) (unit)
Your answer
Your answer
Your answer
Your answer
Your Phone Number *
[area code] prefix-number
Your answer
ACTIVE Email Address
This email address is for the team roster
Your answer
Have you been on a previous BN TEC team?
PART TWO: Waiver Statements and Attachment "A"
Liability Waiver Form
I (full name, above), agree on behalf of myself, my heirs, assigns, executors and personal representatives, to hold harmless and defend Bloomington Normal Teens Encounter Christ and the Catholic Diocese ofPeoria, its officers, agents, employees or representatives associated with this activity from any and all liability claims, loss or damage arising from or in connection with my participation in this TEC Weekend.
I have read, understand and agree with the Liability Waiver, above *
A negative reply will eliminate you from participation on this team
Publicity Waiver Form
On occasion, B/N TEC may take pictures or make audio or video recording of participants involved in activities. Such photographs or video records may be used by staff and participants to commemorate the weekend, or in promotional materials for Teens Encounter Christ. In addition, B/N TEC may invite or allow local news organizations to photograph or record our events to be used, distributed, or displayed as agents of B/N TEC see fit. By clicking yes below, you are giving your consent to be photographed or included in video or audio recordings related to B/N TEC. This consent includes but is not limited to photographs/digital images, video, and audio recordings.
I have read, understand and agree with the Publicity Waiver, above *
A negative reply will eliminate you from participation on this team
Authorization for Emergency Medical Treatment for an Overnight Activity (Attachment "A")
I, [named above], understand that in the case of my illness, B/N TEC will try to notify the person(s) I have listed below as emergency contacts.
In case of a medical emergency concerning myself, at a time when my listed emergency contact cannot be notified, I grant full power to B/N TEC and/or any supervising employee to do as follows:
1. Arrange for my transportation, whether by ambulance or otherwise, to a proper facility where emergency medical treatment would normally be administered, including but not limited to, an emergency room of a hospital, a doctor's office, or a medical clinic; and;
2. Sign releases as may be required in order to obtain any medical or surgical treatment as is required in the judgment of competent medical authorities at the facility.
Please initial in the box below *
Enter your initials to represent your legal signature. By doing so, you are asserting full compliance with the statements in the paragraphs, above.
Your answer
PART THREE: Emergency Contact and Medical Information
Primary Emergency Contact *
This should be a person that will be available to be contacted throughout the TEC Weekend!
Your answer
Primary Phone Number *
(area code) prefix - number
Your answer
Secondary Emergency Contact
Your answer
Secondary Phone Number
Your answer
Your Medical Information
Providing this information will make adult leaders aware of any conditions that might affect your participation during the TEC weekend. It may also assist the TEC Leadership or qualified medical professionals in determining the proper actions in your treatment, if an emergency should arise.
Allergies, Food Allergies, Conditions? :
Please list any applicable and level of severity
Your answer
Regular Physician Name
First ; Last
Your answer
Regular Physician Phone
Your answer
Medical Coverage:
Do you have medical insurance?
Medical Facility Preference:
Your answer
This information will be kept strictly in the possession of an adult leader in charge of this TEC weekend activity. Should the need arise, only then, will this information be given to the proper medical authorities.
PART FOUR: Diocesan Compliance
The Peoria Diocese’s policy on ADULT VOLUNTEERS working with MINOR children is clear and non-negotiable. “All adult Team members(everyone over the age of 17) must have the DCSF CANTS Form and fingerprinting completed prior to the TEC weekend” To read the official letter for use of this policy, see the “Adult Compliance Policy” link on the Team Commitment Forms Page.

If you have NOT previously submitted to a DCFS CANTS and ISP Criminal Records Check (through an agency of the Diocese or your parish), as a volunteer working with children within the Peoria Diocese, you are probably not in compliance. However, you will receive a briefing on this subject during the second or third week of your Team formation and the opportunity to complete ALL the necessary forms and get your fingerprints taken during one of your meetings.

If you HAVE, previously, submitted to a DCFS CANTS and ISP Criminal Records Check for an agency of the Diocese or your parish. (if you have, you will know.) We will verify that your file is current, based on the information you provide on the NEXT PAGE. Positive verification or re-submission is required before you can participate on the TEC Weekend.

I understand the statements above and declare the following: *
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