2019 BYR: SUMMER Reg Form
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BYR: SUMMER RETREAT JUN 30th - JUL 6th, 2019
REGISTRATION/WAIVER/MEDICAL FORM
PRESENTED BY THE BUDDHIST CHURCHES OF AMERICA (BCA) CENTER FOR BUDDHIST EDUCATION (CBE)
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PARTICIPANT INFORMATION
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Participant Name:
Age:Grade:
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District:Chapter:
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Participant Phone#:
Participant Email:
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COMPLETE ONLY IF FLYING IN
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AirlineAny Notes:
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Arrival Flight#/Time
Depart Flight#/time
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PARENT/GUARDIAN INFORMATION (only 1 name required)
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Parent/Guardian(1)
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Parent/Guardian(2)
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Home Address:
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City, State, Zip:
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Parent Phone1:Parent Phone2:
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Parent Email1:Parent Email2:
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HEALTH INSURANCE INFORMATION
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Insurance Company:
Policy #:
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Medical Doctor:Phone Number:
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EMERGENCY CONTACT INFORMATION (NON PARENT/GUARDIAN)
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Contact 1:Relation:
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Phone 1:Phone 2:
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Contact 2:Relation:
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Phone 1:Phone 2:
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MEDICAL/DIETARY/ALLERGY INFORMATION
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List any special medical needs or concerns (allergies, conditions, dietary needs, medication, etc…)
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OTHER INFORMATION
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Any other information that leaders should know about. (behavior, life issues, etc…)
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RECOMMENDING MINISTER
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NAME:
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SIGNATURE:
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PARENT & APPLICANT PLEASE READ & SIGN
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Functions and Activities
This is a program of the Buddhist Churches of America (BCA). Participating in the programs and activities of the BCA is a privilege. By allowing my child to participate in such activities, I acknowledge that there are certain risks associated with the activities, including physical injury due to activity‑related accidents, physical injury due to transportation‑related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

Release of Liability
By signing this Permission/Waiver Form, I expressly warrant that the child named above is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child participating in the activities, whether such risks are known or unknown to me at this time.I further release the BCA and its ministers, leaders, employees, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability is also intended to cover all claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against the BCA or its ministers, leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless the BCA and its ministers, leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.
 
First Aid and Emergency Medical Treatment
I recognize that there may be occasions where the child named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of the BCA to seek and secure any needed medical attention or treatment for the child named above, including hospitalization, if in the agent's opinion such need arises. In doing so I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.
 
Special Events and Field Trips
I understand that the child named above may be participating in service projects and social events during church youth events. I understand that during this period my child/ward may take part in activities such as: minor yard work, cleaning, painting, light labor and other activities consistent with the purposes of the church. I also understand that during this period my child/ward will attend offsite field trips to museums, neighboring temples, or other locations, either by charted bus, public transportation, automobile or walking.


Parent Signature
I represent that I am the parent/guardian of __________________________________________. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof.
 
I give permission for the child named above to participate in the activities and events sponsored by or held by the BCA . In consideration for allowing the participation of the child in the activities of the BCA, I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of the child, and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assignors.

 
Signature of Parent or Legal Guardian _________________________________________ Date _________________

 
Print Name of Parent or Legal Guardian ________________________________________ Date _________________
 
Youth Agreement
I agree to participate in the functions and activities of the BCA, to cooperate with the leaders and other members, and always be on my best behavior. By signing this agreement, I am stating that I am capable of acting in a responsible and mature manner, and am capable of making good decisions. I promise to respect myself, respect all other persons, and respect all property. I will not bring any restricted items to any BCA event. If it becomes necessary for me to be sent home early from an event, this will be done at my parents’ expense. I understand that my continued participation in all BCA activities is a privilege.
 

Signature of JYBA Participant _________________________________________________ Date ________________

 
Print Name of JYBA Participant ________________________________________________ Date ________________
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LIST YOUR ACTIVITIES, HOBBIES OR ANY INTERESTS (TELL US ABOUT YOU!):
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PLEASE ATTACH A LETTER OF RECOMMENDATION(S) FROM A MINISTER, ADVISOR, OR TEACHER
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PLEASE ATTACH A SHORT ESSAY (500 WORDS MAX) ABOUT WHO YOU ARE TODAY,
AND WHO YOU HOPE TO BE 20 YEARS IN THE FUTURE.
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PLEASE MAIL ALL COMPLETED APPLICATIONS AND PAPERWORK TO:
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Jodo Shinshu Center
BYR: Summer Retreat
2140 Durant Avenue
Berkeley, CA 94740

All applications DUE by April 30th, 2019
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