Please fill out one form for each child. Child InfoChild's Name Child's Birthday MM slash DD slash YYYY Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name of Mother First Last Mother's Cell (required)Name of Father First Last Father's Cell (required)Location During General AssemblyHotel Name (during GA 2022) PhoneEmergency InformationMedical Insurance Co. Policy # Name of Primary Policy Holder Medical HistoryList any pre-existing or present medical condition(s):Name and dosage of medication that must be taken:Check the following areas of concern for your child, adding necessary comments below:Does your child have allergies to: Medications Food Insect Bites Other No Allergies Please explain:Does your child require an Epi-pen? Yes No Does he/she know how to use it? Yes No Does your child suffer from, or has ever experienced, or is currently being treated for: Asthma Diabetes Epilepsy/Seizure Disorder Heart Trouble Physical Handicap None Please explain:Does your child have special needs? Yes No Please explain:Date of last Tetanus Shot? MM slash DD slash YYYY Does your child wear glasses or contacts? Yes No Does your child know how to swim? Yes No Should your child's activities be restricted for any reason? Yes No Please explain:Permission and Release AgreementChild's Name My child has permission to participate in all of the activities for his/her age group that are scheduled for the 49th General Assembly in Birmingham, AL. In the event my child becomes ill or is injured while under the supervision of the Nursery, Elementary, or Youth staff, I approve the appropriate authorities taking the following actions: 1. Contact the parent or legal guardian and follow his/her instructions. 2. In the event of an emergency, when neither parent nor guardian can be reached immediately, the General Assembly Host Committee, or authorities of the Presbyterian Church in America are authorized to use their best judgment in contacting a physician or other health care provider and to authorize the provision of necessary medical, surgical, or other care. 3. In the event of such an emergency, I also waive any rights to privacy of any medical information related to the emergency, in order that the appropriate care might be obtained. In consideration of the General Assembly Host Committee, Evangel Presbytery and the Presbyterian Church in America (a Corporation) making available the 49th General Assembly Nursery, Elementary and Youth activities, I hereby waive, release and discharge its agents, volunteers and employees from any and all claims and liability of any kind or nature. We have read the above and understand this release. Furthermore, in the event of an emergency, said care providers have our permission to administer first aid or obtain emergency medical treatment in our child’s best interest. We agree to pay all expenses incurred due to an emergency involving our child. Photo Release: Presbyterian Church in America and its legal representatives and assigns, retain the right and permission to publish, without charge, photographs taken during the General Assembly. These photographs may be used in publications, including electronic publications, or in audio-visual presentations, promotional literature, advertising, or in other similar ways. Medical Release: While we do our best to provide the safest possible environment for our events, the Presbyterian Church in America cannot be held responsible for any medical emergencies that occur during the General Assembly. Cancellation Policy: If you must cancel, please request a refund in writing by email to: GA2022Reg@gmail.com. There are no refunds after June 8, 2022. Consent* I understand this is a Release and with that knowledge, I voluntarily sign it. By entering my first and last name below, I am signing this document.Name* First Last Date* MM slash DD slash YYYY Additional Comments:
