Birmingham Vida Nueva

Participant Medical Release

This form must be completed and appropriately signed by ALL WEEKEND PARTICIPANTS, and/or parent, or legal guadian of applicant prior to the commencement of the weekend activitities.  This completed form will be held by the Birmingham Vida Nueva Council representative (or designated party) during the course of the weekend.

Weekend Participant Information

BVN does stock over the counter (OTC) medications for the weekend.  If you give permission for the medical cha to provide OTC medication (i.e. Tylenol, Advil, Naproxen, Benadryl, Peto-Bismol) to your minor child, please check yes below.  OTC medications are used to treat symptoms such as headaches, allergies or upset stomach. *

Participant Insurance Information

In checking below, I as a weekend participant, acknowledge that I understand that at no time are minors (ages 19 and younger) permitted to wander around the campground unsupervised.  I agree to follow the schedule of the weekend, and stay within my assigned dorm once the team has been dismissed for the night.  (This includes, but is not limited to, going into the lake, hiking to the cross, or walking the trails.)  I understand that the result of not complying will result in being dismissed from the weekend and parents/legal guardians notified.  Team fees will not be refunded. *
In the event of an emergency, I as parent or legal guardian of above named candidate, do hereby authorize an adult of Vida Nueva as agent for me, to consent to myself or minor child, receiving any X-ray, exam, medical, dental, or surgical diagnosis, treatment, and hospital care advised by a physician, surgeon, dentist, as appropriate, licensed to practice under the laws of the state where services are rendered, either at a doctor's office or in any hospital.  I aurthorize the release of medical information to appropriate medical personnel and/or Health Insurance Company.  I shall be obligated for all costs relative to any medical assistance and/or services rendered.  In addition, I have, and do hereby, release Birmingham Vida Nueva, Inc., it's directors, or agents, from all liability associated with participation in Birmingham Vida Nueva.
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Signature of Weekend Participant *
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Signature of Guardian (if under 19 years of age)
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