YM Camp Adult Medical Release

Young Men's Camp Adult Medical Release

Young Men's Camp Adult Medical Release

(Required by the State of California Rules & Regulations)
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Health Insurance Provider*
Health Insurance Policy Number*
Adult Camper Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Last Tetanus Vaccination:*

MonthDayYear
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.
VegetarianVeganGluten-freePeanut AllergyEgg AllergyDairy AllergyNo fish/shellfishNo allergies
Please provide any additional food allergy/special dietary need information here
Weight*
Height*
Penicillin Based medicationsSulfa Based MedicationsSiprofloxacinOther
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.

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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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Medication

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