Youth Medical Release
(Required by the State of California Rules & Regulations)
Camper Name
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First Name
Last Name
Level
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1st Year
2nd Year
3rd Year
4th Year
YCL
Date of Birth
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-
Month
-
Day
Year
Date
Health Insurance Company
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Health Insurance Policy Number
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Last Tetanus Vaccination:
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-
Month
-
Day
Year
Date
Primary Care Doctor
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Primary Care Doctor Phone Number
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Emergency Contact
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First Name
Last Name
Emergency Contact Phone Number
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Please enter a valid phone number.
Alternate Emergency Contact
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First Name
Last Name
Alternate Emergency Contact Phone Number
*
Please enter a valid phone number.
Food Allergies/Intolerances/Dietary Requirements (Check all that apply)
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Vegetarian
Vegan
Gluten-free
Peanut Allergy
Egg Allergy
Dairy Allergy
No fish/shellfish
No allergies
OTC medications my child may NOT have
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Tylenol/Acetaminophen
Motrin/Advil/Ibuprofen
Benadryl/Antihistamines
Antacids(Tums, etc)
None
Other
Weight
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Height
*
Drug Allergies
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Penicillin Based medications
Sulfa Based Medications
Siprofloxacin
Other
List all medication you will be taking to camp
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Please check...
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Had it Past
Currently Have
Never Had
Poison Oak
Fainting
Rheumatic Fever
Chronic Sore Throat
Chronic Nose Bleed
Heart Condition
Chronic Headache
Eye Problem
Chronic Ear Infection
Lung Disease/Asthma
Recent Surgery
Recent Injury
Physical Disabilities
ADHD/ADD
Anxiety/Depression
History of Sleepwalking
Back Problems
Convulsions
Recent Serious Illness
Thyroid Problem
High Blood Pressure
Sleep Disorder
Allergy to Insect Bite/Sting
None
Any other Medical issues not listed above
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Health Authorization: This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted by me. Medical Consent: I do hereby authorize Walnut Creek Stake adult leaders to act as agent(s) for my child to consent to any X-ray examination, anesthesia, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any accredited hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician, in the exercise of his/her best judgment, may deem advisable. This authorization is given pursuant to the provisions of Section 25.6 of the Civil Code of California. This authorization shall remain effective until the above-mentioned Minor’s or Adult Camp Participant’s last day at Walnut Creek Stake YW’s Camp 2025). Acknowledgment, Consent Authorization: The undersigned hereby acknowledges that he/she is the legal guardian or parent of the minor designated herein below and as such has legal authority to execute documents on his/her behalf. In that regard, the undersigned understands and acknowledges that the adult or minor designated below will be attending the Walnut Creek Stake YW’s Camp and other facilities in conjunction with YW’s Camp from July 14, 2025 through July 19, 2025. They will be participating in various outdoor activities that are physically strenuous. The undersigned is not aware of any physical or psychological conditions or impairments that would prevent or limit the adult’s or minor’s participation in these activities. Additionally the undersigned agrees to hold the Church of Jesus Christ of Latter-Day Saints and the individual organizers of the event harmless from any and all claims arising from the adult’s or minor’s participation in the aforementioned activities. Furthermore the adult camp participant or parent/guardian of designated minor also grants to the leaders of the above referenced trip; the power to determine the necessity, type and kind of medical treatment, provided that if there is no medical emergency, the leaders will first use reasonable efforts to contact said parent/guardian before administering or authorizing any treatment and/or hospitalization.
PLEASE REVIEW THIS SECTION MOST CAREFULLY TOGETHER WITH YOUR DAUGHTER: Our goal with the Walnut Creek YW Stake Camp is to provide the young women with a place where they can gather together, separate from worldly influences, feel the Spirit of the Lord, grow in unity and love, and strengthen their faith and testimonies of Heavenly Father and Jesus Christ. At camp, the young women have the world of nature as their classroom. It is an opportunity for young women to practice patterns of gospel living away from worldly influences and the challenges they may face in their daily lives. Camp creates an outdoor hiking and living experience with an emphasis on social, spiritual, educational, and recreational activities. YW are encouraged to try new activities and camp provides opportunities to learn archery, quilt tying, and certification in some outdoor living skills. Additionally there are recreational opportunities for crafts, swimming and canoeing at the waterfront, playing games, and most importantly spending time in nature, studying the scriptures, pondering Gospel truths and the applications in their lives.CODE OF CONDUCT: We hope camp can be a wonderful experience for you, where your testimony of the Gospel of Jesus Christ is strengthened, and that you feel a closer connection to your Heavenly Father as His precious daughter. Our aim is to provide ample experiences for you to feel the Spirit as we worship together, and build friendships together. This can best be achieved as each of you focus on being a friend and ministering to those around you, as well as seeking to comfort and bear the burdens of those around you. Camp can be a stressful place for some as they’re staying in a new environment away from home. Be mindful of this -- extending love and friendship can be a blessing to all. Please be kind to those around you at camp.Cooperate with your leaders at all times. This includes showing respect by following the camp rules and following directions from your leaders. Substances that are contrary to the Word of Wisdom (alcohol, tobacco in any form, including vaping, coffee, other drugs) are not permitted at camp. Avoid profanity, swearing, lying or stealing. Show respect by not violating the personal property of others. Keep Gospel Standards in all your actions as outlined in For the Strength of Youth.A primary purpose of spending time at camp is to strengthen testimonies of and faith in Heavenly Father and Jesus Christ. Those who attend should avoid disruptions or distractions contrary to this purpose. As such, there are behavior requirements that must be followed and respected at all times. That requires refraining from overt romantic behavior and from dress and grooming that causes distraction. In addition, participants should avoid making political statements or speaking unkindly of themselves or others in a way that detracts from camp’s purpose of focusing on Heavenly Father and Jesus Christ.If there is inappropriate behavior, the level leaders and/or Camp Directors/Stake YW Presidency will counsel privately with you in a spirit of love. We will encourage behavior that helps to maintain a sacred space for everyone present. If there continues to be behavior that is contrary to the guidelines that have been set forth, your parent/guardian will be asked to promptly come pick you up. It is important to understand that participation in camp is not a right, but a privilege that may be revoked if there is inappropriate behavior or if you pose a risk to yourself or others.
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Confirmation: BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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