Menu
Plymouth Adventist Church
Plymouth Adventist Church
_
About Us
Contact Us
Directions
What We Believe
Church News
Worship and Prayer
Worship Service Speaking Plan
'Listen Again' Sermon Podcasts
Prayer Requests
Explore Our Beliefs
Young People and Children
Youth Meetings
Pathfinders and Adventurers
Explore Our Beliefs
Gallery
Let's Go To Cape Town 16-30 Dec 2019
Leave this field blank
Leave this field blank
Leave this field blank
* Indicates required field.
Name
First
Last
Address
Address 1
Address 2
City
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Postal Code
Country
Phone Number
Date of Birth
Email
EMERGENCY CONTACT (Name, Relationship to You, Telephone/Mobile Number)*
Any Dietary Allergies?
Medical Information*
Please tick if you have any of the following:
Rheumatic Fever Asthma
Fainting Spells
Diabetes
Kidney Disease
Heart Trouble
Hernias
Travel Sickness
Epilepsy
Other (Indicate in box below)
None of the Above
Any other Medical Illnesses not indicated above.
Have you been given any specific advice to follow in emergencies?
Are you taking any medication we should be aware of? If yes, please give name of drug and dosage details:
Please give details of any current/past illnesses or medical conditions of which we should be aware of.
Health Information (Please enter name of GP, Address and Telephone Number)*
Current regulations relating to Child Protection issues and taking photographs of young people require that we obtain your consent for any picture taken that includes you and/or your son/daughter and which is used in either video or printed publication. No names will be published or the individuals identified except in association with those who may know him/her.
Please tick here to indicate your consent.
Tick
If it becomes necessary for you to receive medical treatment and no-one can be contacted by telephone or any other means to authorise this, please tick the appropriate box to indicate your consent to any necessary medical treatment and authosrise the event leader (or in their absence one of the assistant leaders) to sign any document required by the hospital authorities.*
(This part particularly applies to under 16's where Parental consent is needed)
YES
NO
If it is considered necessary do you agree to mild painkillers (e.g. Paracetemol) being administered?
(This part particlarlyapplies to under 16's where parental consent is needed)
YES
NO
If you accept responsibility to correctly and clearly label with the name and exact dosage any medication your child requires as well as hand the medication over to the leader before departure, please indicate by ticking the appropriate box.
(Only fill this in if the application refers to child under 16)
YES
NO
Please indicate that you read and understood, and answered all previous questions appropriately to the best of your knowledge*
YES
Enter your name and date to indicate as signature and agreement to the above.*