Koinonia Application

Vida Nueva Online Application

Part A – Sponsor and Applicant Information

Applicant Information

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Cell Phone:

Other Phone:

Email Address:

Nickname:

Birthdate:

Age:

Sex:

T-shirt size (adult):

School Grade:

School you attend:

Church you attend:

Parent/Guardian First Name:

Parent/Guardian Last Name:

Parent/Guardian Cell Phone:

Parent/Guardian Email Address:

Are there any special diet needs or food allergies? Select yes or no and provide details if needed.

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Vida Nueva Online Application

Part B – Candidate Medical Release Form

Candidate Medical Release

This form must be completed and appropriately signed by all weekend participants, parent (or legal guardian) prior to any weekend activities. The form will be held by the Vida Nueva Council Representative for the duration of any weekend.

Select yes or no and provide details if needed. Please indicate any and all:

Medical allergies

Medical conditions

Will medications need to be given during this Vida Nueva weekend?

I consent to child receiving over the counter medications such as Tylenol or Advil:

Any other information?

Medical Insurance Company:

Group #:

Member #:

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Vida Nueva Online Application

Medication Tracking Log

Candidate Medication Tracking Log

The Medication Tracking Log is required to be completed by a candidate’s parent (or legal guardian) in order to ensure all medication is properly administered as it relates to type, amount, and frequency of medication.

MEDICATION TO BE GIVEN DURING THE VIDA NUEVA WEEKEND

	Medication	Dosage	Frequency/ Usual Time Taken	Reason

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Vida Nueva Online Application

Application Sign and Submit

Sign and Submit Application

Electronic Consent

By submitting this application online, by clicking the 'Submit Application' button below, you are consenting to submit an electronic application to Vida Nueva of Southeast Tennessee. At any time, you may request an paper copy of any data submitted online. Please click 'Submit' below if the application is complete.

Medical Consent (Applicant Under 18 Years Old)

In the event of an emergency, I, as parent (or legal guardian) of do hereby authorize an adult Vida Nueva leader as agent for me, to consent to my child receiving an x-ray, exam, medical, dental, or surgical diagnosis, treatment, and hospital care advised by a physician, surgeon or dentist as appropriate, licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I shall be obligated for all costs relative to any medical assistance and/or services rendered on behalf of . I release Vida Nueva from any legal responsibility related to medical treatment.

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Application Submission Complete

Success!

Your application has been successfully submitted.

You will also need to fill out and sign a COVID release form for the Apison Retreat Center. You can find it here:

Apison Retreat Center COVID Release VNSETN (pdf)

If you'd like to submit your $100 application fee via PayPal, use the link below: