Jesus Prom 2017 Prommers

Prommer Information

*Address Line 1
Address Line 2
*Zip/Postal Code
*Date of Birth
*Meal Preference:
Please list any medication or treatment the Prommer will need while on site?
*Does the guest have any history of unwanted sexual contact or assault within the last 5 years?
If you selected yes to the previous question, please explain:

Caregiver & Emergency Contact Information

If attending with a group, please list Agency Name and Phone Number
*Number of Caregivers Attending:
*Caregiver Name:
*Caregiver Phone Number:
*Emergency Contact Name:
*Emergency Contact Phone Number:
In the event the Prommer/Caregiver suffers an injury or condition during his/her participation in the activities, including transportation to and from the activities, which may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if medical treatment is delayed, and reasonable attempts to contact me or the designated alternate contact person have been unsuccessful, to the extent allowed by local law, I hereby appoint the attending Southland staff member or agent, as the Prommer's/Caregiver agent to act for them and in my name (in any way I could act in person) to make any and all decisions for the Prommer/Caregiver concerning his/her personal care, medical treatment, hospitalization, and health care. This power of attorney and delegation of authority shall terminate when the agent is able to contact me or the designated alternate contact person: