Registration

BOYS2MEN 2023–24
Registration

Registration Form

* Indicates required field

First Name *

Middle Name *

Last Name *

Birth Day Date *

Address *

CIty *

Grade Entering: *

State *

Zip *

Email *

Cell Phone *

Allergies: Food or Other (Circle One): *

Yes No

If Yes, please explain: *

Emergency Contact Information:

Parent/Guardian: *

State *

Address *

Zip *

Alternate Person *

Relationship: *

Phone Number *

BY SIGNING BELOW the parent or legal guardian allows the above-named registrant to participate in the activities of BOYS2MEN.

Parent/Guardian Signature: *

Max file size: 100 KB

Date *

(Print Name of Parent or Guardian of Minor) *

, am the parent or legal guardian of

Print Name of Minor *

(hereinafter “my child”), who was born.

Birthday Date *

Child is attending and participating in activities located at 487 Front St., Berea, OH 44017, beginning on the day of

MM/DD/YYYY *

I hereby authorize Chris Scott, Director, and his officers, agents, volunteers, or employees that are 18 years of age or older, who supervise the activities of BOYS2MEN into whose care my child has been entrusted, to consent to medical care or dental care, or both, for my child under the Ohio Family Code.

The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child.

I further authorize the Director and his/her officers, agents, volunteers or employees that are 18 years of age or older, who supervise the activities sponsored by BOYS2MEN, to receive physical custody of my child, under the Ohio Health and Safety Code, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the Director and his/her officers, agents, volunteers or employees that are 18 years of age or older who supervise the activities at BOYS2MEN.

Understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the Director or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.

Parent/Guardian Signature *

Max file size: 2MB

Sign Date *

Health Insurance Information Sheet

(Medical/Health Insurance Company) *

Child Allergies/Allergic reactions to: *

Insurance Policy No *

Medicine being taken by my child: *

In case of emergency, notify.

Parent/Guardian *

Address *

City *

State: OH *

ZIP *

Alternate Person *

Relationship *

Phone *

Registration

BOYS2MEN 2023–24Registration

Registration Form

Emergency Contact Information:

​​Health Insurance Information Sheet

​In case of emergency, notify.

BOYS2MEN 2023–24
Registration

Health Insurance Information Sheet

In case of emergency, notify.