HEALTH AND PERMISSION
FORM
for YOUTH
DELEGATES and YOUTH VISITORS
MAINE CONFERENCE OF THE UNITED CHURCH OF CHRIST
2009 Annual Meeting, Grand Summit Hotel, Sunday River, Bethel, ME
PARENTS & YOUTH DELEGATES & YOUTH VISITORS:
This form is required for all participants at sessions who were in grades 9-12
during this school year.
Youth Delegates and Youth Visitors without this form will not be allowed to
attend the sessions.
THIS IS NOT A REGISTRATION FORM. Health Forms must be completed in addition to Registration Forms.
________________________________________________________________________________________ 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 (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 25-27, 2009 to be held at Sunday River, Bethel, ME
I hereby release the Maine Conference, UCC, its 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 emergency, I authorize an adult leader as agent for me,
to consent to any x-ray examination: medical, dental, or surgical diagnosis, treatment; and hospital 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 contacted as soon as possible.
Signature of Parent or Legal Guardian _______________________________________________________________
___________/________/________________
Today's Date
Phone #’s where you can be reached: ______________________________________
Person to contact if parents are unavailable______________________________________
Phone number of contact______________________________________
Relationship to youth:__________________________________________
Return this form to Sue Stevens
- Maine Conference UCC- P.O. Box 966 - Yarmouth, ME 04096-1966.
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 as the sponsor.
If no relative is attending, ask at your church for a sponsor, making sure that
they know their responsibilities.
At the Annual Meeting, the Youth Delegate or Youth Visitor will make the effort
to remain in contact with their sponsor.