2026 YM Camp YM Medical Form

Youth Medical Release

Camper Name

First NameLast Name

Level

Date of Birth

Date

Health Insurance Provider

Health Insurance Policy Number

Camper Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Last Tetanus Vaccination:

Date

Primary Care Doctor

Primary Care Doctor Phone Number

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

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

Alternate Emergency Contact

First NameLast Name

Alternate Emergency Contact Phone Number

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

Food Allergies/Intolerances/Dietary Requirements (Check all that apply)

Please provide any additional food allergy/special dietary need information here

OTC medications my child may NOT have

Note any additional OTC medications not allowed for named camper

Weight

Height

Drug Allergies

Other

Medications: ALL MEDICATIONS MUST BE CHECKED IN TO THE HEALTH SUPERVISOR AS DIRECTED

List prescription medications that will be taken by camper while attending Camp. If there are any changes to this list prior to the beginning of Camp, such changes MUST be communicated to the Health Care Supervisor before arrival at Camp. All medication must be in original container with original pharmacy medication sticker including camper's name.

NOTE: PLease check the box for morning, noon, or evening as appropriate for administering of each medication

Please check if camper presently has or has ever incurred any of the following:

Rows	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

Please note any other medical concerns that may restrict participation in camp activities

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 Young Men’s Camp 2026). 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 Young Men’s Camp and other facilities in conjunction with Young Men’s Camp from June 29, 2026 through July 4, 2026. 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 YOUNG MAN: Our goal with the Walnut Creek Stake Young Men's Camp is to provide the Young Men 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 Men have the world of nature as their classroom. It is an opportunity for young men 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. Young Men are encouraged to try new activities and camp provides opportunities to learn archery, axe throwing, bb gun shooting, and certification in some outdoor living skills. Additionally, there are recreational opportunities for art, 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 son. 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 YM 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.

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.

Medication

Related Condition