Participant Information

1
Event
2
Date(s)
3
Date(s) of event
Date
Month
Day
Year
4
Describe event and activities (please be specific)
Play in the water at the lake. Ride in power boats and ski.
5
Ward* This field is required.
6
Stake
7
Event or activity leader
8
Leader's Phone
9
Event or activity leader’s email
example@example.com
10
Participant's Name* This field is required.
11
Date* This field is required.
Date
Month
Day
Year
12
Participant's Date of birth* This field is required.
Date
Month
Day
Year
13
Age
14
At time of event
15
Participants Phone* This field is required.
16
Participants Secondary Phone
17
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
18
Emergency contact (parent or guardian)* This field is required.Name
19
Emergency phone number* This field is required.
20
Emergency secondary phone number
21
Does the participant require a special diet?* This field is required.
YES
NO
22
Please explain the dietary restrictions* This field is required.
23
Does the participant have any allergies?* This field is required.
YES
NO
24
Please list the allergies* This field is required.
25
Does the participant take any medications of any kind?* This field is required.
YES
NO
26
List all prescription or OTC medications the participant is taking* This field is required.
27
Can the participant self-administer their medication?* This field is required.
YES
NO
28
Does the participant have a chronic or recurring illness?* This field is required.
YES
NO
29
Please Explain* This field is required.chronic or recurring illness
30
Has the participant had surgery or a serious illness in the past year?* This field is required.
YES
NO
31
Please Explain* This field is required.surgery or a serious illness
32
Identify any other limits, restrictions, or disabilities that could prevent the participant from fully participating in the event or activity.* This field is required.
33
Identify any other needs or considerations the participant has that the event or activity planner should be aware of.* This field is required.
34
Parent or Guardian / Do you Agree?* This field is required.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. Conduct at Church Activities Church events and activities can be fun, uplifting, and spiritually strengthening for everyone who attends. To reach these aims, all participants are invited to commit to follow the principles taught in For the Strength of Youth: A Guide for Making Choices. When you do, the experience will be better for everyone. Please note that Church activities are not the time or place for romantic behavior or for conversations and actions that distract from the purpose of the event or activity. If you participate in any of the following prohibited activities, leaders at the event or activity will speak with you, your parents, and your bishop or stake president. These leaders may decide to send you home immediately. • Participating in or encouraging immoral behavior of any kind, which includes breaking the law of chastity or viewing or distributing pornography in any form • Shoplifting, theft, or vandalism of any kind • Breaking the Word of Wisdom, including vaping and possessing illegal or harmful substances • Possessing weapons or dangerous items of any kind (if specifically authorized, certain items may be provided and used in supervised activities) • Harming or threatening to harm yourself or others physically, spiritually, or emotionally, including bullying in any form or disrupting another’s experience • Leaving without following proper procedures, skipping scheduled activities without permission, or breaking curfew Crimes and harmful or destructive incidents or pranks may be reported to local authorities, who will respond according to local law. Leaders follow the direction of these authorities.
YESNO
35
By clicking NO on the previous field you are not elegable to participate.
36
Participant's Signature* This field is required.
Clear
37
Parent or Guardian's Signature (If Necessary)
Clear
38
Would you like a copy of this form to be mailed to you?A copy will automatically be email to Tasha McNamee
YESNO
39
Your Email Address* This field is required.
example@example.com
Should be Empty: