Girls Camp Adult Medical Release
(Required by the State of California Rules & Regulations)
Name
*
First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Insurance Company
*
Health Insurance Policy Number
*
Date of Last Tetanus Vaccination:
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-
Month
-
Day
Year
Date
Primary Care Doctor
*
Primary Care Doctor Phone Number
*
Emergency Contact
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First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Emergency Contact
*
First Name
Last 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)
*
Vegetarian
Vegan
Gluten-free
Peanut Allergy
Egg Allergy
Dairy Allergy
No fish/shellfish
No allergies
Other
Please list all routine medications you will be taking while at camp:
Rows
Medication
Purpose
Dosage
Frequncy
Med 1
Med 2
Med 3
Med 4
Med 5
Please list any DRUG allergies, write NONE if it does not apply.
*
Please list any FOOD allergies, write NONE if it does not apply.
*
Please list any OTHER allergies (bees, seasonal, etc), write NONE if it does not apply.
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Please check...
*
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
Any other Medical issues not listed above
*
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 myself 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 Adult Camp Participant’s last day at Walnut Creek Stake YW’s Camp 2026). Acknowledgment, Consent Authorization: The undersigned hereby acknowledges that he/she is the adult participant. In that regard, the undersigned understands and acknowledges that the adult will be attending the Walnut Creek Stake YW’s Camp from June 15, 2026 through June 20, 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 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 participation in the aforementioned activities. Furthermore the adult camp participant 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 emergency contact before administering or authorizing any treatment and/or hospitalization.
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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