Church Permission Slip

Complete this form separately for each event or activity involving special considerations (see Handbook 2: Administering the Church, 13.6.20, ChurchofJesusChrist.org), an overnight stay, travel outside the local area, or an activity with higher than ordinary risks.

Event: Antelope Stake Trek 2021 Date of event: July 29, 20, 31 2021

Describe event and activities (please be specific): Pioneer handcart trek with 2 overnight camps

Stake: Antelope

Event or activity leader: Patrick Elmer

Event or activity leader phone number: (916)207-6519

Event or activity leader email: elmerpe@churchofjesuschrist.org
Participant Information
Participant*
Date of birth*

MonthDayYear
Date
Age*
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact (parent or guardian)*
Primary telephone number*
Work
Medical Information
Does the participant require a special diet?*

YesNo
If yes, please explain the dietary restrictions
If yes, please explain the dietary restrictions
Does the participant have any allergies?*

YesNo
If yes, please list allergies.
Is the participant taking any medication or over-the-counter (OTC) drugs?*

YesNo
If yes, can the participant self administer his/her medication

YesNo-if no please contact the event or activity leader directly
List all prescription or over-the-counter (OTC) medications the participant is taking
If yes, can the participant self-administer his or her medication?
Physical Conditions That Limit Activity
Does the participant have a chronic or recurring illness?
Has the participant had surgery or a serious illness in the past year?*

YesNo
If yes, please explain
Identify any other limits, restrictions, or disabilities that could prevent the participant from fully participating in the event or activity (attach additional pages if needed)
Other Accommodations or Special Needs
Identify any other needs or considerations the participant has that the event or activity planner should be aware of (attach additional pages if needed)
Permission
I give permission for my child or youth to participate in the event and activities listed above (unless noted) and authorize the adult leaders supervising this event to administer emergency treatment to the abovenamed participant for any accident or illness and to act in my stead in approving necessary medical care. This authorization shall cover this event and travel to and from this event.

The participant is responsible for his or her own conduct and is aware of and agrees to abide by Church standards, camp or event safety rules, and other pertinent instructions. Participants’ conduct and interactions should abide by Church standards and exemplify Christlike behavior. Parents and participants should understand that participation in an activity is not a right but a privilege that can be revoked if they behave inappropriately or if they pose a risk to themselves or others.
Participant's Signature*

Clear
Date*

MonthDayYear
Date
Parent/Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Parent or guardian’s signature (if necessary)
© 2017, 2019 by Intellectual Reserve, Inc. All rights reserved. 5/19. PD60004035 000
List all prescription or over-the-counter (OTC) medications the participant is taking
If yes, please explain
If yes, please explain
Should be Empty:

Participant Information

Medical Information

Physical Conditions That Limit Activity

Other Accommodations or Special Needs

Permission