2021 Tamarack Senior Registration – Northern California Nevada Conference

Participant First Name*

Participant Last Name*

Participant Date of Birth*

Participant Address*

Street Address Address Line 2 City State ZIP Code

Participant Phone

If participant does not have their own phone number, LEAVE BLANK

Participant Email Address

If participant does not have their own email address, LEAVE BLANK

Grade Completed in 2020*

Participant T-Shirt Size

Family Details

NCNC-UCC Local Church Affiliation

If Non NCNC-UCC Church, Name and City of Local Church

Parent/Guardian #1 Name (First & Last)*

Parent/Guardian #1 Phone (With Area Code)*

Parent/Guardian #1 Email Address*

Parent/Guardian #2 Name (First & Last)

Parent/Guardian #2 Phone (With Area Code)

Parent/Guardian #2 Email Address

Accessibility & Accommodations

Housing Preference

Recognizing the full spectrum of gender identity and expression while acknowledging the binary limitations of many spaces, we seek to accommodate our participants to the fullest of our abilities. Please select the housing preferences which apply to this participant.

Female-identified housing
Male-identified housing
Non-binary identified housing

Physical Accommodations Required?

Please describe any physical accommodations that are necessary for the participant's fullest experience

Dietary Restrictions

Behavioral Adaptations?

Please describe any ongoing behavioral adaptations that staff should be aware of to best support the participant

Health & Wellness

Medical Insurance Carrier

Medical Insurance ID Number

Physician Name

Physician Phone

Dentist Name

Dentist Phone

Optometrist Name

Optometrist Phone

Ongoing Health Concerns?

Mental Health Concerns?

Type and Dosage of Prescription Medication

List Over-the-Counter Medication NOT to be Dispensed

Allergies & Sensitivities?

Any Additional Pertinent Health Details?

Participant is Up-to-Date with California School Immunizations?

Yes
No

Date of Last Tetanus Shot

Transportation and Medical Release

All drivers transporting youth must be age 21 or older. Youth may not be released to drivers between 18-21 years of age.

Name of Adult Transporting Participant TO Site

Name of Adult Transporting Participant FROM Site

Consent*

I agree to transportation and medical release

Any adult member of the camp staff, plus the persons listed here, have my permission to transport the named minor participant to/from programming site location. Further, I grant permission to the person(s) listed here and camp staff to act as my agent while transporting my child, in authorizing any x-ray, examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care which is deemed advisable by and is rendered under the general or special supervision of any physician and surgeon licensed under the provision of the Medicine Practice Act. The foregoing to occur only after reasonable efforts to contact the parent/guardian have been unsuccessful. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

Media Release

Consent

I AGREE to the media release

I hereby give consent for NCNC-UCC to use any of the photographs or videos taken of my minor child at this event for publicity, such as for future event brochures or marketing materials. With consent I hereby release NCNC-UCC from any claim whatsoever that may arise in this regard. I understand that a group photograph may be taken.

Payment

Registration Level*

Early Bird ($250)

Coupon Code (if applicable)

Total

$0.00

Credit Card

Card Details

Cardholder Name

Billing Address*