2015 NGP Porto Pollo Clinics
12 - 17 April 2015
Porto Pollo, Sardinia
A Next Generation Project Event
Hello and Welcome to the registration form of the Next Generation Project. Please fill in everything correctly and check it again before sending. As soon as this is done, we will send you a mail with confirmation of your participation and give your more explanation concerning the payment. See you at the Clinic and be part of the Next Generation !!
Last name*
First name(s)*
Address
Town/City
Postcode
Country
Phone*
Email*
Gender*
Male
Female
Date of Birth*
vb. DD/MM/YYYY
Size*
XS
S
M
L
XL
XXL
Entery Free*
Clinics - €290
Clinics - €290 + Extra's [MAKE SURE TO MARK THE EXTRAS YOU NEED!]
Rental
- -50% of normal price
Storage -
Comming soon!
Food; Lunch + snack- €10/Day
Emergency contact & Health information
Emergency Contact Name*
Relationship
Home Address
Home Phone
Mobile or Cell Phone*
Email*
Authorisation
*
I, the parent / guardian have legal custody of the minor. I hereby authorize the responsible adult to act as my nominated person at the clinic. I agree that this authorization shall remain in effect for the duration of the minor’s participation in the event and related activities and shall not be revoked before the end of the clinic.
Non-Liability of the organization
*
I agree that in no event will the organization, their parent companies, affiliates, or the partners, owners, directors, officers, employees, agents and committee persons have any liability whatsoever arising from or in connection with any action or non-action of the responsible adult
.
Agreement
*
By submitting this form I certify that I have carefully read, understand and agree to the above agreement and non-liability statement.
.
Medical information
Name of doctor/Physician
Medical Center Name and Adress
Phone Number*
A value is required.
Invalid format.
Important Medical History
Medication
Allergies
Futher information
Date of last anti-tetanus*
A value is required.
Invalid format.
vb. DD/MM/YYYY
Consent*
I hereby authorize the responsible adult named above to give permission for my child to receive any emergency dental, medical or surgical treatment, including anesthetic, as considered necessary by the medical authorities present.
Parent/Guardian Name*
Medical Insurance Company*
Policy#*
Value
Submit copy of policy to organisation by
email
or upon arrival at the clinics.
© Britt Van der Eyken - 2013
