2023 Santa Maria Stake YW Camp
Permission and Medical Release Form
Event: Stake Girls Camp Event Date: June 20-24 2023
Participant Information
Name of Participant
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age Participant Will Be at Camp
*
Participant Phone Number
*
-
Area Code
Phone Number
Parent Name
*
First Name
Last Name
Parent Phone Number
*
-
Area Code
Phone Number
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ward
*
Five Cities
Oak Knolls
Orcutt Hills
River Bridge
Sierra Madre
Stake
*
Santa Maria
Other
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Medical Information
Does the participant require a special diet?
*
Yes
No
If yes, please explain the SPECIFIC dietary restrictions and allergies:
Does the participant have any allergies?
*
Yes
No
If yes, please list the allergies:
Is the participant taking any medication or over-the-counter (OTC) drugs?
*
Yes
No
If yes, can the participant self-administer his or her medication?
*
Yes
No
If no, please explain:
List all the prescription or over-the-counter (OTC) medications the participant is taking:
Physical Conditions That Limit Activity
Does the participant have a chronic or recurring illness?
*
Yes
No
If yes, please explain:
Has the participant had surgery or a serious illness in the past year?
*
Yes
No
If yes, please explain:
Identify any other limits, restrictions or disabilities that could prevent the participant from fully participating in the event or activity:
Identify any other needs or considerations the participant has that the event or activity planner should be aware of:
Permission
I give permission for my child/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 above-named 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 her own conduct and is aware 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.
Date
*
-
Month
-
Day
Year
Date
Participant's Signature
*
Parent or Guardian's Signature
*
Submit
Should be Empty: