2023 Medical and Insurance Information + Release

2023 NCF-Envirothon New Brunswick Competition
Mount Allison University
Tantramar (aka, Sackville), New Brunswick, Canada
Dates: July 23 - 29, 2023

NCF-Envirothon is committed to respecting the privacy of our students, advisors, and guests. The information provided will remain confidential and only shared with key individuals (i.e., legal guardians, team advisor/chaperone, emergency contact, medical personal, etc.) in the case of medical emergencies or illness.

Medical & Insurance Information and Release

All Student Team Members, Advisors, Chaperones, and Guests are REQUIRED to complete this form in order to attend the 2023 NCF-Envirothon New Brunswick competition.

Please Note:
- • Proof of Medical Insurance is Required - An electronic copy (picture or scan) of the attendees Medical Insurance information (card) should be uploaded to this form (follow the directions below). Please have a scan or photo of the front and back of the medical insurance card available in order to proceed. Uploaded copies of Insurance information, will be deleted upon conclusion of competition.
- • A Parent or Legal Guardian will be needed to complete this form if the participant is under the age of 18.
Deadline: June 10, 2023*
* Students, Team Advisors/Chaperones, and Guests from Maine, Ohio, and Maryland have an additional 7 days from the conclusion of their state Envirothon competition to complete all Required Registration Forms:
a. Maine - due on June 14
b. Ohio - due on June 20
c. Maryland - due on June 23
State/Province/Partner Nation registered participant is representing: *
Name of Registered Participant: Name of Registered Participant: * First Last
Preferred Pronouns
Participant is registered as a: *

Participant is registered as a: Student Team Member Student Team Member Substitution Candidate Team Advisor/Chaperone Guest
Participant's Email *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth * / MM / DD YYYY
Is the registered participant 18 years of age or older? *

Is the registered participant 18 years of age or older? Yes No
Parent/Legal Guardian

Reminder: If the participant is under the age of 18, a Parent or Legal Guardian will be needed to complete the form.
Parent/Legal Guardian Name Parent/Legal Guardian Name First Last
Parent/Legal Guardian Home Phone Parent/Legal Guardian Home Phone - ### - ### ####
Parent/Legal Guardian Cell Phone Parent/Legal Guardian Cell Phone - ### - ### ####
Parent or Legal Guardian Email
Relationship to Registered Participant
Emergency Contact Information

Parent, guardian, spouse, relative or other that will be contacted in the case of a medical emergency.
Name Name * First Last
Cell Phone Cell Phone * - ### - ### ####
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Email
Relationship to Registered Participant *
Additional Emergency Contact(s): please provide name, contact #s, and relationship status to participant
MEDICAL INFORMATION
Gender *

Gender Male Female Self Describe Self Describe

Please select any health concerns which may recur during the event or be a factor in any medical treatment: *
	Yes	No
Asthma	AsthmaYes	AsthmaNo
Diabetes	DiabetesYes	DiabetesNo
Food-based Allergy	Food-based AllergyYes	Food-based AllergyNo
Medication-based Allergy	Medication-based AllergyYes	Medication-based AllergyNo
Allergy to latex	Allergy to latexYes	Allergy to latexNo
Physical Disability	Physical DisabilityYes	Physical DisabilityNo
Epilepsy or other seizure condition	Epilepsy or other seizure conditionYes	Epilepsy or other seizure conditionNo
Other	OtherYes	OtherNo

If you selected 'Other', please list below:
Food-Based Allergies

Please list all food-based allergies (eggs, dairy, fish, shellfish, wheat, soy, gluten, sesame, etc.) *
Medication-Based Allergies

Please list all medication-based allergies (antibiotics, sulfa drugs, aspirin, etc.) *
Other Allergies

Please list any other allergies we should be aware of in the event of an emergency (insect bites and stings, animal dander, latex, etc.) *
Special Need

If you have a disability or special need and may require accommodations in order to fully participate or be treated in case of emergency, please indicate below: *
Medications

Please list all Medications you are taking that medical personal should be aware of in the event of an emergency *
Physician/Medical Provider Information
Physician's name and/or name of Medical Practice where your medical history is kept *
Physician's Phone Number Physician's Phone Number - ### - ### ####
INSURANCE INFORMATION

As part of the NCF-Envirothon annual international competition, each individual in attendance must provide proof of health insurance. For individuals not currently covered under any health insurance plan, a temporary limited policy can be obtained to cover the timeframe of the competition. A minimum of 7-14 days is recommended to cover all travel to and from the event location as well as the 6-days of the competition itself.

Please make sure you have an electronic copy of the front and back of the individual's medical insurance card to complete this form.
Name of Insurance Company *
Insurance Company Phone Insurance Company Phone * - ### - ### ####
Primary Card Holder Name on Insurance Policy
(self/parent/legal guardian/spouse) Primary Card Holder Name on Insurance Policy
(self/parent/legal guardian/spouse) * First Middle Last
Primary Card Holder Email *
Proof of Insurance - Card Upload

PDF, JPG, TIF, PNG or GIF are preferred file formats
Front of Insurance Card *

Attach Files
Back of Insurance Card *

Attach Files
COVID-19 AND EVENT PARTICIPATION RELEASE, WAIVER, and INDEMNITY AGREEMENT

For the 2023 NCF-Envirothon New Brunswick Competition

TO THE PARTICIPANT AND THE PARENT/GUARDIAN (if the individual attending is under age 18): THIS DOCUMENT IS A RELEASE, WAIVER AND INDEMNITY THAT AFFECTS YOUR LEGAL RIGHTS. READ THOROUGHLY BEFORE SIGNING. IF YOU DO NOT UNDERSTAND YOUR LEGAL RIGHTS OR HAVE ANY QUESTIONS OR CONCERNS ABOUT THIS DOCUMENT, OBTAIN INDEPENDENT LEGAL ADVICE BEFORE YOU SIGN IT.
I have read the above NCF-Envirothon COVID-19 and Event Participation Release, Waiver and Indemnity Agreement and agree to the following: *

I have read the above NCF-Envirothon COVID-19 and Event Participation Release, Waiver and Indemnity Agreement and agree to the following: (i) I sign this Agreement voluntarily and without any coercion or undue influence and without any expectation or promise by NCF/NCF-Envirothon or its Representatives. (ii) I acknowledge receipt of a full copy of this AGREEMENT. (iii) I acknowledge the assumption of the risk from COVID-19, Other Viruses and Communicable Illnesses. (iv) I acknowledge and agree to abide by all COVID-19 Preventative Measures put in place and enforced by NCF/NCF-Envirothon and Representatives to reduce the spread of COVID-19. (v) I acknowledge and agree that failure to comply with COVID-19 Preventative Measures may result in disciplinary action, including but not limited to disqualification from the event and/or immediately being sent home at mine or my parent/legal guardian’s expense.
Draw your signature into the box below to acknowledge your agreement to the above.
(If participant is under the age of 18, please have a Parent/Legal Guardian sign here!) *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
MEDICAL and INSURANCE INFORMATION + RELEASE CONFIRMATION
Registered Participant Approval *

Registered Participant Approval I certify that all information provided is correct
Participant's Signature: Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Parent/Legal Guardian Approval (if participant is under the age of 18)

Parent/Legal Guardian Approval (if participant is under the age of 18) I certify that all information provided is correct
Parent/Legal Guardian: Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Thank you.

2023 Medical and Insurance Information + Release

2023 Medical and Insurance Information + Release

Parent/Legal Guardian

Reminder: If the participant is under the age of 18, a Parent or Legal Guardian will be needed to complete the form.

Emergency Contact Information

Parent, guardian, spouse, relative or other that will be contacted in the case of a medical emergency.

MEDICAL INFORMATION

Physician/Medical Provider Information

Proof of Insurance - Card Upload

PDF, JPG, TIF, PNG or GIF are preferred file formats

COVID-19 AND EVENT PARTICIPATION RELEASE, WAIVER, and INDEMNITY AGREEMENT

For the 2023 NCF-Envirothon New Brunswick Competition

MEDICAL and INSURANCE INFORMATION + RELEASE CONFIRMATION

Thank you.

2023 Medical and Insurance Information + Release

2023 Medical and Insurance Information + Release

Parent/Legal Guardian Reminder: If the participant is under the age of 18, a Parent or Legal Guardian will be needed to complete the form.

Emergency Contact Information Parent, guardian, spouse, relative or other that will be contacted in the case of a medical emergency.

MEDICAL INFORMATION

Physician/Medical Provider Information

Proof of Insurance - Card Upload PDF, JPG, TIF, PNG or GIF are preferred file formats

COVID-19 AND EVENT PARTICIPATION RELEASE, WAIVER, and INDEMNITY AGREEMENT For the 2023 NCF-Envirothon New Brunswick Competition

MEDICAL and INSURANCE INFORMATION + RELEASE CONFIRMATION

Thank you.

Parent/Legal Guardian

Reminder: If the participant is under the age of 18, a Parent or Legal Guardian will be needed to complete the form.

Emergency Contact Information

Parent, guardian, spouse, relative or other that will be contacted in the case of a medical emergency.

Proof of Insurance - Card Upload

PDF, JPG, TIF, PNG or GIF are preferred file formats

COVID-19 AND EVENT PARTICIPATION RELEASE, WAIVER, and INDEMNITY AGREEMENT

For the 2023 NCF-Envirothon New Brunswick Competition