YW Camp Permission and Medical Release Form

Permission and Medical Release Form
Each participant (including leaders) completes this form separately for each event or activity involving an overnight stay, travel outside the local area, or higher than ordinary risks (see General Handbook: Serving in The Church of Jesus Christ of Latter-day Saints, 20.5.5, 20.7.4, 20.7.7 The event or activity leader should have access to all participants’ forms during the activity.

Event Details (to be filled out by event planner)
Ward*
Contact Information
Participant*
Date of birth*

MonthDayYear
Date
Age*
Telephone Number*
Address*

Address

Street Address Line 2

CityState or province

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

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

YesNo
If yes, please list the allergies.
List all prescription or over-the-counter (OTC) medications the participant is taking. Leave blank if none.
Can the participant self-administer his or her medication?

YesNo
Conditions That Limit Activity
Does the participant have a chronic or recurring illness?*

YesNo
If yes, please explain.
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.
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 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. Please note: Units may not have the ability to meet all medical, physical, and other accommodations and are asked to counsel with parents or guardians on what is possible. 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. The participant’s conduct and interactions should abide by Church standards and exemplify Christlike behavior, including those listed on the attached “Conduct at Church Activities.” Parents and participants should understand that participation in an activity is not a right but a privilege that can be revoked if participants behave inappropriately or if they pose a risk to themselves or others. This information is collected to help event and activity leaders or medical personnel so they can be prepared and appropriately respond to health concerns or an emergency. It will be kept confidential and shared only as needed.

By typing your full legal name, you affirm that this is your electronic signature and that you are providing it with the intent to sign this document.
Participant's Signature:*
Date*

MonthDayYear
Date
Parent or Guardian's Signature (if participant is a minor):
Date

MonthDayYear
Date
© 2024 by Intellectual Reserve, Inc. All rights reserved. 2/24. PD60004035 000
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 harm ful 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.

© 2024 by Intellectual Reserve, Inc. All rights reserved. 2/24. PD60004035 000
Should be Empty:

Permission and Medical Release Form

Contact Information

Medical Information

Conditions That Limit Activity

Other Accommodations or Special Needs

Permission

Conduct at Church Activities