PARENTS & YOUTH DELEGATES & YOUTH VISITORS:
This form is required for all participants at sessions who were in grades 9-12 during this school year.
Return to CHERYL TIBBETTS - P.O. Box 966 - Yarmouth, ME 04096-1966.

THIS IS NOT A REGISTRATION FORM. REGISTRATION FORMS ARE ONLINE.

Youth Delegates and Youth Visitors without this form will not be allowed to attend the sessions.

______________________________________________________________________________________________________
Name Birth date (month/day/year)

______________________________________________________________________________________________________
Address (Street name/Rural route, City, State, Zip Code)

______________________________________________________________________________________________________
Phone number (Include. area code) H.S. Grad. Year Local Church

______________________________________________________________________________________________________
Name of adult sponsor at Annual Meeting - must be 21 or over - see information below.

Mother’s name (& address if different from yours):________________________________________________________

Father’s name (& address if different from yours):_________________________________________________________

MEDICAL INFORMATION:________________________________________________________________________

Allergies:__________________________________________________ Date of last tetanus shot:____________________

Medications being taken: _______________________________________________________________________________

Family Doctor:_____________________________________________Phone#:_____________________________________

Medical Insurance Company:____________________________________________________________________________

Policy Number:_____________________________________ Member’s Name:____________________________________

I give permission for my above-named child to
participate in the Annual Meeting of the Maine ________________________________________
Conference UCC, Sept 22-24, 2006 to be held Signature of Parent or Legal Guardian
at Sunday River, Bethel, ME
___________/________/________________________
I hereby release the Maine Conference, UCC, its Today’s date
staff & volunteers, as well as Sunday River,
from liability for any injury or illness that my child ___________________ __________________
may sustain during this event. In case of an emer- Phone #’s where you can be reached
gency,I authorize an adult leader as agent for me,
to consent to any x-ray examination: medical, ___________________________________________
dental, or surgical diagnosis, treatment; and hos- Person to contact if parents are unavailable
pital care advised and supervised by a physician,
surgeon or dentist, (as appropriate) either at a ___________________________________________
doctor’s office or in any hospital. I expect to be Phone number of contact
contacted as soon as possible.
Relationship to participant_________________________

Information about adult sponsors:

Q. Why have adult sponsors at the Annual Meeting?

A. It is a policy of the Maine Conference UCC that participants age 17 years and under be “in the care and supervision of a registering participant above the age of 21.”

Q. Who can be an adult sponsor?

A. An adult sponsor is someone 21 years or older who will be attending the Annual Meeting and agrees to:

• Check with the Youth Delegate or Youth Visitor at the beginning and periodically during the Annual Meeting to see that things are going okay

• Inform the Youth Delegate or Youth Visitor where they are living on campus

• Contact parents and/or help the Youth Delegate or Youth Visitor get the care needed for illness or injury during the meeting

• In the event of extenuating circumstances, help make arrangements for the Youth Delegate or Youth Visitor to return home

If a parent or other relative is attending the Annual Meeting they would be the person to list. If no relative is attending, ask at your church for a sponsor, informing them of what is expected.

At the Annual Meeting, the Youth Delegate or Youth Visitor will make the effort to remain in contact with their sponsor.