GLR EVENT REGISTRATION FOR YOUTH

Unity Chapter or New Thought Chapter

Name

Nickname for nametag

Participant is a:

Uniteen Y.O.U.

Birthday

Grade of Youth?

T-Shirt Size (adult sizing)

XS S M L XL 2XL 3XL

Gender

Cabin Preference

Male Female Gender Neutral

Youth Address

Parent/Guardian Name

Parent/Guardian Phone Number

Parent/Guardian Email (Confirmation email sent here)

This address will receive a confirmation email

Relationship to Youth

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship To Youth

First Retreat

Yes No

Number of Retreats Attended

DIETARY HISTORY

Meal Preference (Check all that apply)

Vegetarian Vegan Omnivore Gluten free Lactose Intolerant

List Food Allergies

Non Life-threatening food sensitivites

MEDICAL HISTORY

The above-named participant is in good health and is able to participate in all event activities. Please select one option.

Yes No

If no, specify limits of participation.

Allergies to Medicine

Yes No

If yes, please list:

Participant is currently under a Doctor's supervision for: (Please select one option.)

Epilepsy Diabetes Asthma ADD/ADHD Other Not under a Doctor's Care

If other,or special care needs, please list:

At Youth Events, prescription medications for minors must be turned over to adult leaders with clear usage instructions. This means a prescription bottle for that individual with their name, medication, and dosage. If a medication is "As Needed", your minor must understand the symptoms of his/her condition and be capable of asking for help from adult leaders.

Please list current medications amount taken and times taken. If child is not taking medication - PLEASE INDICATE NO MEDS TAKEN

Date of Last Tetanus Shot

Please list which over-the-counter medications you DO NOT want dispensed to this minor. Please select all that apply.

Aspirin Acetaminophen (e.g. tylenol) Nasal Decongestant (e.g. Sudafed) Pepto Bismal, Tums or Pepcid Ibuprofen (e.g. Advil, Motrin) Cough Suppressant (e.g. cough drops) None of the above can be given All can be given.

Family Physician (Optional)

Family Physician Phone (optional)

Medical Insurance Company

Medical Insurance Phone

Policy Holder's Name

Policy Number

A hospital WILL require the pariticpant's social security number, or the Guardian's if the participant is a minor before treating or admitting the participant. We will contact you should we need this information.

As legal guardian of the above-named minor, I hereby give permission for my youth to participate in this event and to travel to/from the event location. Whenever it may be deemed necessary. I authorize the calling of a doctor and/or the providing of other necessary medical services and, unless covered by insurance, agree to pay for same. I understand that reasonable measures will be taken to safeguard the health and safety of young people and that I will be notified as soon as possible in case of emergency. Should the Local Chapter and Great Lakes Region accept this minor as a participant, I agree to indemnify and hold harmless from responsibility the Church, the Association of Unity Churches (Unity Worldwide Ministries), the Great Lakes Region of the Association, their employees, volunteers, agents, representatives and group leaders in the event of sickness or accident involving the above -named minor, no matter how caused. I hereby attest that I have read the complete document; all information is complete and true: I have legal standing to make decisions which affect the rights of the above named participant: and I understand and consent to all terms outlined in this registration document.

TRANSPORTATION:
I understand that my church group will be responsible for and inform me of the mode of transportation for this event. I agree to send my child with the appropriate clothes, personal items, and money needed. If my child needs to be sent home for behavior problems or medical reasons, I agree it will be at my expense.

Parental/Guardian Signature Required, This is legally binding

PHOTOGRAPHY:

I hereby grant the GLR and it's representatives, permission to use photographs and videotaped images from this event in which my child appears, in any manner whatsoever, such as but not limited to publication, display, advertising, sliude shows, etc.

Parental/Guardian Response: Please select one option.

Yes No

Parent/Guardian Signature Required:

CONFIDENTIALITY:

I understand that health information on this form will be secured and will only be shared, as needed, with adult leaders, church staff and medical professionals to safeguard and support the participant. This informatiobn will not be publicly disseminated or released to any outside organization.

Parental/Guardian Response. Please select one option.

Yes No

Parent/Guardian Signature Required:

HEART AGREEMENTS

Please click on the link to the Heart Agreement that applies to you. Make sure you and your parent/guardian (if you are a teen) read the Heart Agreement. You will be required to sign that you have read the "Heart Agreement" before submission and completion of this Registration Form.

Uniteen Heart Agreement

Y.O.U. Heart Agreement

Type Your Signature that You Have Read and will Follow the Heart Agreement

GLR EVENT REGISTRATION FOR YOUTH

Description

Please Fix the Following