1. Healthcare

Application deadline:
March 22, 2015 • 1:00 pm
Mail applications to:
TEC of West Michigan • Kathy Door
8620 Freeland
Byron Center, MI 49315
616-915-4398
www.westmichtec.org
OFFICE USE ONLY
Ck # ________
Cash _______
You will be notified by e-mail if you are accepted (include your e-mail address below).*
Acceptance letters will be sent shortly after the deadline.
Candidate Application for TEC #60
April 10–12, 2015
Students, please complete the front of this application;
Parents, please complete the back.
l
60 wil
TEC # ld at:
be he
Fellowship Reformed Church
6610 - 36th Ave
Hudsonville, MI 49426
616-669-1213
Church _____________________________________
RDo NOT list my contact information on the TEC candidate list.
Name ___________________________________________
Church Location (City) ________________________
Address __________________________________________
Church Phone/E-mail _________________________
City/State/Zip _____________________________________
Pastor or Youth Pastor _________________________
Birthdate ___________ Phone # ______________________
Have you applied to TEC previously?
RNo
RYes, I applied for TEC # __________
E-mail address* ___________________________________
Where did you hear about TEC? _________________
T-shirt size RS RM RL RXL RXXL Gender: RM RF
___________________________________________
School _____________________ Graduation Year _______
___________________________________________
Details to know about the weekend:
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TEC is meant for high school seniors, juniors, and sophomores. Preference is given to seniors. Freshmen also accepted if
space is available.
Smoking, drinking, and the use of other illegal drugs will not be tolerated at any time during the weekend.
Candidates are expected to be present for the entire TEC weekend (Friday at 10:00 am through Sunday evening).
Candidates are encouraged to come to the TEC reunion on April 26, 2015 (1–3 pm).
The cost of the TEC weekend is $50. (Make checks payable to TEC of West Michigan.) The check must accompany this
application, but will not be cashed until the TEC weekend. Full or partial scholarships are available based on need; they
must be arranged prior to the weekend. To arrange a scholarship, download the form found on the TEC website
(www.westmichtec.org); call Kay Vos at 616-450-0557 with questions.
Cancellation Policy: Cancellation received more than one week before TEC, full refund; cancellation between two days
and one week before TEC, half refund; cancellation less than two days before TEC, no refund. However, you may receive a
voucher to be used at a future TEC for any money not refunded.
Photos taken during the weekend may be used in printed or on-line TEC promotions, unless you make a special request
that photos of you not be used (group photos will be on-line).
______________________________________
__________________________________
Participant’s Signature
Printed Name
______________________________________
__________________________________
Parent or Guardian’s Signature
Printed Name
This application may be reproduced.
__________________
Date
__________________
Date
TEC Candidate Application/Parent or Guardian Section
Father/Male Guardian
Mother/Female Guardian
Name _________________________________________ Name _________________________________________
Address ________________________________________ Address ________________________________________
City/State/Zip ___________________________________ City/State/Zip ___________________________________
Phone # ________________________________________ Phone # ________________________________________
Work/Cell Phone # _______________________________ Work/Cell Phone # _______________________________
E-Mail Address __________________________________ E-Mail Address __________________________________
Additional Emergency Contact Person (to be used only if we are unable to contact parent/guardian)
Name _________________________________________ Phone # _______________________________________
MEDICAL RELEASE FORM
In the event of a medical emergency, I hereby give permission to the physician selected by the TEC leadership to secure
proper treatment for my child as named below. I certify that no insurance guarantee has been made as to the results
that may be obtained. I further release West Michigan TEC from liability for any physical injury that my child might
incur in conjunction with the TEC weekend.
I, ____________________________, the (select one)
R Father
R Mother
R Guardian
(parent/guardian name)
of ________________________________ hereby authorize TEC of West Michigan to seek any emergency medical
(student name)
treatment needed for my child.
Insurance Company Name ___________________________________________
Policy Number ____________________________________________________
Amount of Co-pay _________________________________________________
Please list any special medical needs, allergies, or dietary needs your child has, or if your child is a vegetarian.
MEDICATIONS USED/SPECIAL NEEDS/RESTRICTIONS: ____________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
ALLERGIES: ___________________________________________________________________________________
______________________________________________________________________________________________
DIETARY NEEDS: ______________________________________________________________________________
______________________________________________________________________________________________
Parent Signature _____________________________________________ Date _____________________________
Application deadline: March 22, 2015 • 1:00 pm
Mail applications to: TEC of West Michigan • Kathy Door, 8620 Freeland, Byron Center, MI 49315, 616-915-4398
You will be notified by e-mail if you are accepted (include your e-mail address on front page).*
Acceptance letters will be sent shortly after the deadline.
This application may be reproduced.
www.westmichtec.org