Episcopal Diocese of Texas - Division of Youth Ministry
http://www.epicenter.org/youth/yes | 800.318.4452
YES Participant Application (Adults)
Deadline: Two (2) weeks before the YES weekend you wish to attend.
YES Fee: $65 (For scholarship info, contact the Lay Director)
All payments, online or by check, MUST be received prior to the YES Weekend.
First Name
*
Goes By
Last Name
*
Age
*
Please Select
18-20
21-30
31-40
41-50
51-60
61-70
Gender
*
Please Select
Male
Female
Participant Home
*
-
Area Code
Phone Number
Participant Cell
*
-
Area Code
Phone Number
Adult Participant Email
*
Home Church (Name, City)
*
YES You Wish To Attend
*
Please Select
YES #107 (Aug 24-26, 2012)
YES #108 (Nov 16-18, 2012)
T-Shirt Size
*
Please Select
Small
Medium
Large
X-Large
2X-Large
Please tell us why you are interested in attending YES as a participant:
*
Medical and Insurance Information
IMPORTANT: SEND COPY OF BOTH SIDES OF INSURANCE CARD WITH PARTICIPANT TO EVENT ... (NOTE: Prescribed Medicines must be in original pharmacy container with correct name, date, instructions, and physician’s name on label)
Chronic or Recurring Illnesses (Asthma, migraines, etc.)
*
Medical Allergies, Reaction, Treatment
*
Food Allergies, Diet Restrictions
*
Medications Being Sent with Participant
*
Any over-the-counter medications the participant may not receive:
*
Health Carrier, Policy #, Group #, Address, Phone
*
Any other issues, concerns, etc. for the Event Coordinators or Nurse to be aware of?
Emergency Contact Information
(NOTE: The Sponsors of this event do not provide insurance in case of injury or illness.)
Contact Name and Relationship
*
Cell Phone
*
-
Area Code
Phone Number
Home Phone
*
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Area Code
Phone Number
Second Contact Name and Relationship
Cell Phone
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Area Code
Phone Number
Home Phone
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Area Code
Phone Number
Participant Name
*
Medical Permission/Release
I, shown as participant name, am a willing participant in Youth Encounter Spirit (YES), to be held at Camp Allen in Navasota, TX sponsored by the Episcopal Diocese of Texas. I represent that I am healthy and capable of participation in said event without causing risk of danger, illness or accident to myself, or to others. I agree to hold harmless the leaders of my church, leaders of other churches involved, the event coordinators, the Bishop of Texas and the Diocese of Texas in the event of any accident or injury. In the event that I require medical attention while attending the event, I understand that an adult sponsor of the event will make every reasonable attempt to contact my emergency contact. I consent to any medical attention deemed appropriate. In the event that treatment is called for, which the medical provider refuses to administer without consent, I hereby authorize an adult sponsor to give such consent for me. In the event that it is necessary for that person to give consent, I agree to hold such person free and harmless of any liability for damages arising from giving such consent. I will notify the Event Coordinator or Nurse if I have been exposed to any communicable disease 3 weeks prior to this event. I declare that I am covered by medical insurance and/or that I am responsible for any and all expenses incurred whether covered under insurance or not.
Multimedia Permission/Release
By my signature below, I hereby grant permission to the event sponsors to use images or sound recordings of me, shown as participant name, captured during the course of this YES event (including any pre-event meetings). These images include but are not limited to, digital or still photography, audio or sound recordings, or video images, with the intended use for educational material during the event and the possible future use in online and social media for promotional and marketing purposes. I release the event sponsors from any expectation of confidentiality or privacy.
Participant Name
*
Signature, Date
Safeguarding God’s Children
Anyone 18 and older, or not a student, who attends a YES staff meeting or YES weekend must have the following on file with their parish or school: 1. Results of reference checks, 2. Signed Code of Conduct and Acknowledgement and Release, 3. Background check results (within 5 years), 4. Safeguarding God’s Children certificate for a 3 hour training (within 5 years). This form must be signed by a parish or school staff person with direct knowledge of compliance with above. If the parish or school cannot attest to having these documents on file, the participant may not be allowed to attend.
Safeguarding Verification/Confirmation
I verify that the participant, shown as participant name, has met the Safeguarding God’s Children requirements and that the necessary information is on file at the parish or school.
Parish/School Staff Person with Knowledge
*
Signature, Date
Please review your application before submitting. You will receive an email approximately 2 weeks prior to the weekend with additional details concerning the weekend. You will need to bring a copy (front and back) of your insurance card.
Options to Pay Your Application Fee:
To contact the Lay Director about a possible scholarship, email pamcj@att.net.
Select One:
Mail check to Diocese
Home church will pay all fees
Pay online with Credit Card or PayPal
Pay by Check
Make checks payable to: Episcopal Diocese of Texas. Mail checks to: Y.E.S. c/o Division of Youth, Episcopal Diocese of Texas, 1225 Texas Avenue, Houston, TX 77002.
Home Church Will Pay
If this is offered by your Home Church, contact your youth minister to ensure your fee is included in their payment.
Pay Online
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YES Application Fee
$
65.00
Dummy
$
Free
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