Bowling LockIn Reg From and Consent Form 2010

Jr.
High Bowling Lock-In Registration Form

January 14-15, 2011 @ Annandale UMC & Falls Church Bowl America
Early Registration $25 by Jan. 9. Regular Reg. $28 by Jan. 12. Late Reg. $30 by
Jan. 14 (if available)
For more details, please contact pastor Keon (Gun) Huh (703-342-6778)
The registration will NOT be accepted without non-refundable reg. fee.
Medical Release/Liability Consent Form

BASIC INFORMATION
Male / Female / /
Name Gender Date of Birth (mm/dd/yyyy)
Address City State Zip
E-mail Phone 1 Phone 2
School Grade T-shirt Size
PARENTAL CONSENT transportation costs.
The undersigned does hereby give permission for

our (my) child, _____________________________, The undersigned does also hereby give permission
to attend and participate in Jr. High (Bi-District) for our (my) child to ride in any vehicle designated
Bowling Lock-In (Jan. 14-15, 2011). We (I) by the adult in whose care the minor has been
authorize an adult, in whose care the minor has entrusted while attending and participating in
been entrusted, to consent to any X-ray activities sponsored by KUMCGW.
examination, anesthetic, medical, surgical or dental
diagnosis or treatment, and hospital care, to be MEDICAL INSURANCE
rendered to the minor under the general or special
supervision and on the advice of any physician or
dentist licensed under the provision of the Medical INSURANCE COMPANY NAME
Practice Act on the medical staff of a licensed

hospital, whether such diagnosis or treatment is INSURANCE COMPANY ADDRESS
rendered at the office of said Physician or at said

hospital. The undersigned shall be liable and CITY STATE ZIP
agree(s) child to return to pay all costs and
expenses in mentioned child pursuant to this NAME OF INSURED PHONE
authorization. Should it be necessary for our (my)
child to return home due to medical reasons or
POLICY # PHYSICIAN PHONE
otherwise, the undersigned shall assume all
Name of Parent/Guardian of the Applicant Phone 1 Phone 2
Signature of Parent Date
*For further medical concerns, please fill out on the back of this page
Jr. High Bowling Lock-In Registration Form
MEDICAL INFORMATION
Is your son/daughter currently under the care of a physician for a medical problem? Yes ____ No _____
If yes, please explain....
____________________________________________________________________________
________________________________________________________________________
Is your son/daughter currently taking medication prescribed by a physician? Yes ______ No ______
If yes, please list each medication and circle whether or not it needs refrigeration.
___________________________________________________________ Requires Refrigeration
___________________________________________________________ Requires Refrigeration
Please list any over-the-counter medications you do not wish dispensed to your child for treatment for minor
ailments or injuries.
___________________________________________________________________________________________
_______________________________________________________________________________________
Does your son/daughter have any of the following medical conditions?

If yes, please explain any details under the condition:
Chronic health problems? Yes ______ No ______
___________________________________________________________________________________________
_______________________________________________________________________________________
Allergies (e.g. food, bee stings, medications)? Yes ______ No ______

___________________________________________________________________________________________
_______________________________________________________________________________________
Program limitations? Yes ______ No ______

Jr. High Bowling Lock-In Registration Form
___________________________________________________________________________________________
_______________________________________________________________________________________
Is there any other information about your son/daughter that an attending physician needs to be aware of?
If yes, please explain...
___________________________________________________________________________________________
_______________________________________________________________________________________
Date of Last Tetanus / / Date of Last MMR / /

Bowling LockIn Reg From and Consent Form 2010

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Bowling LockIn Reg From and Consent Form 2010

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Jr.

High Bowling Lock-In Registration Form

Medical Release/Liability Consent Form

Name Gender Date of Birth (mm/dd/yyyy)

Address City State Zip

E-mail Phone 1 Phone 2

School Grade T-shirt Size

PARENTAL CONSENT transportation costs.

The undersigned does hereby give permission for

Practice Act on the medical staff of a licensed

rendered at the office of said Physician or at said

Name of Parent/Guardian of the Applicant Phone 1 Phone 2

Signature of Parent Date

___________________________________________________________ Requires Refrigeration

Does your son/daughter have any of the following medical conditions?

Allergies (e.g. food, bee stings, medications)? Yes No

Program limitations? Yes No

Date of Last Tetanus / / Date of Last MMR / /

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