CGVN Candidate Application v4.1
Sponsor Page
Sponsor Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sponsor Phone Number
Please enter a valid phone number.
Best Contact Time
Sponsor Email
example@example.com
Candidate Name
First Name
Last Name
Gender
Please Select
Male
Female
Candidate Name
First Name
Last Name
Candidate Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Youth Email
example@example.com
Youth Phone Number
Please enter a valid phone number.
Candidate Birthday
-
Month
-
Day
Year
Date
T-Shirt Size
Please Select
Small
Medium
Large
XL
2XL
3XL
4XL
Signature
Emergency Contact
First Name
Last Name
Medical Insurance Provider
Policy Number
PCM Contact Info
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CGVN Candidate Application 4.1
Administration of Medicine Form
Candidate Name
First Name
Last Name
Medication 1
Prescription Number 1
Medicine Dispensing Time
Hour Minutes
AM
PM
AM/PM Option
Dosage and Method
ex - 10 mg with food
Medication 2
Prescription Number 2
Time
Hour Minutes
AM
PM
AM/PM Option
Dosage and Method 2
Name of Medication 3
Prescription Number 3
Time 3
Hour Minutes
AM
PM
AM/PM Option
Dosage and Method
Name of Medication 4
Prescription Number 4
Time
Hour Minutes
AM
PM
AM/PM Option
Dosage and Method 4
Name of Medication 5
Prescription Number 5
Time 5
Hour Minutes
AM
PM
AM/PM Option
Dosage and Method
List any allergies (food, environment etc.) or any other pertinent health information
Parent / Guardian (Print)
Parent / Guardian Signature to Authorize the dispensing of Medicine(s)
Date
-
Month
-
Day
Year
Date
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Participant / Candidate Name (Print)
First Name
Last Name
CGVN Candidate Application v4.1
COVID Release Form (SHORT)
(For Youth Participants) Parent COVID Release Signature
(For Youth Participants) Parent / Guardian Print Name
First Name
Last Name
(For Youth Participant)
-
Month
-
Day
Year
Date
Adult Participants - COVID Release Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: