Vida Nueva of North Georgia Application

Sponsor Address:  

City: State: Zip:

Email Address:

Sponsor Home Phone: Sponsor Other Phone:

As a sponsor, I acknowledge my responsibilities to this Applicant/Candidate and his/her family.  I have read and understand the purpose of Vida Nueva. 

By typing my name in this box, I am signing this application.

Sponsor Confirmation:  

APPLICANT/CANDIDATE INFORMATION:  

Candidate Name (First and Last):  

Name they go by (Nickname):

 Candidate Address:  

City: State: Zip:  

Home Phone: Other Phone:  

Age: Sex: Birthdate (mm/dd/yyyy):

 Email:  

Church: Denomination:  

School you attend:

By having the candidate type their name here, they are agreeing that they have read the purpose of Vida Nueva and are agreeing to attend a weekend.

 Applicant Confirmation:

PART B – VIDA NUEVA OF NORTH GEORGIA

PARTICIPANT MEDICAL RELEASE AND ATTENDANCE CONSENT

For All Weekend Participants

This form must be competed and appropriately signed by all weekend participants prior to commencement of weekend activities.   This completed form shall be held by the Vida Nueva Council Representative during the course of the weekend.

Please indicate any and all medical allergies, medications being taken, medical problems or conditions, special diets (for valid, diagnosed medical conditions), or any other pertinent information. 

Participant Medical Insurance Company:  

Group Number: Member Number:  

Father's or Male Guardian's Name:  

Father's or Male Guardian's Home Phone:  

Father's or Male Guardian's Work Phone:  

Father's or Male Guardian's Cell Phone:

Mother's or Female Guardian's Home Phone:  

Mother's or Female Guardian's Work Phone:  

Mother's or Female Guardian's Cell Phone:

In the event of an emergency, I, as parent or legal guardian of the weekend participant named above, do hereby authorize an adult Vida Nueva leader as agent for me, to consent to the weekend participant named above to receive any X-ray, exam, medical, dental or surgical diagnosis, treatment, and/or hospital care advised by a physician, surgeor, or dentist, as appropriate, licensed to practice under the laws of the state where the services are rendered, either at a doctor's office or in any hospital.  I shall be obligated for all costs relative to any medical assistance and/or services rendered on behalf of the weekend participant named above. 

I confirm that entering my name in the space provided herein shall be construed the same as if it were my written signature.  Further, I agree to and shall be bound by the obligations in the above Medical Release Statement.

Confirmation (Parent or Guardian name):  

Emergency contact name: Emergency Phone:

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In the event of injury or illness, the participant may be transported in the most effective and efficient manner to the Chestatee Regional Hospital 227 Mountain Drive, Dahlonega, Georgia 30533; Phone No. (706) 864-6136 for appropriate medical treatment and/or subsequent transport to a specialized facility recommended by the aforesaid hospital.

Please make sure that all information is complete and correct.  This information will be sent to the Vida Nueva of North Georgia Pre-Weekend Couple.  If you have any further questions about this application, contact Jeff & Tonja Terry at 770-459-5831.

Please print a copy of this information before submitting.  Mail the signed medical release form to the Pre-weekend couple or bring it to send-off.  We must have a signed original before your candidate can attend the weekend.

Printed name ____________________   Signature __________________________