SP - Permission & Medical Release Form

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*

Ex. Trek, FSY, YM Campout, Etc.

Participant's Ward*

Participant Name*

First NameLast Name

Participant Date of Birth*

Date

Participant Age *

On date of activity

Participant's Cell Phone Number*

If participant does not have a phone please use parent/guardian's phone numberFormat: (000) 000-0000.

Participant's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact (parent or guardian)*

First NameLast Name

Emergency Contact's Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Does the participant require a special diet?*

YesNo

Please explain the dietary restrictions*

Does the participant have allergies?*

YesNo

Please list the allergies*

Is the participant taking any medication or over-the-counter (OTC) drugs?*

YesNo

Can the participant self-administer their own medication?*

YesNo

List all prescription or over-the-counter (OTC) medications the participant is taking*

Does the participant have a chronic or recurring illness?*

YesNo

Please explain the chronic or recurring illness*

Has the participant had surgery or a serious illness in the past year?*

YesNo

Please explain the surgery or serious illness*

Are there any limitations, restrictions, or disabilities that could prevent the participant from fully participating in the event or activity that has not been identified?*

YesNo

Please explain the limitations, restrictions, or disabilities that could prevent the participant from fully participating*

Is the participant 18 or older?*

YesNo

By signing below, 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*

Date Signed*

Date

Signature of Parent/Guardian (must match name of Emergency Contact above)*

Date Signed*

Date

Permission and Medical Release Form