League
City Texas Stake
APPLICATION
FOR YOUNG WOMEN SUMMER CAMP 2015
March
16-19 2015 – Camp Edgewood
Parental or
Guardian Permission and Medical Release for all Young Women and Leaders
Please
provide ALL information before returning
Participant: _____________________________________ Date
of Birth _______________
Address:
___________________________________________________________________________
Parent or Guardian:
_________________________________________________________
Home Phone: __________________________________ Emergency
Phone: _________________________
If
non-member or visiting from another stake, please note who you are attending
with:
_____________________________________________________________
Participant’s Ward: ___________________________________
Grade in school completed this
year (circle) 6 7 8
9 10 11
12 Age at Camp ___________
Certification level you will be
working on this year or your position (please circle):
1-- First year YL--
Stake Junior Counselor
2-- Second year UL--
Unit Leader
3--Third year Stake
Staff
4--
Fourth year
T-shirt Size (circle one): S
M L XL
XXL
Camp Fee: $100 (includes Trading Post)
COMMITMENT: I
recognize that my attitude can influence others and I will try to contribute
all that I can to make this an enjoyable camp for everyone. I will try to learn all that I can, make new
friends, and will be a credit to my ward or branch by living the standards of
The Church of Jesus Christ of Latter-day Saints in my thoughts, dress, and
actions while at summer camp. I know
that when a camp rule is broken by me knowingly, I may be sent home without
completing the duration of camp.
Signature
of camper _____________________________________ Date: ______________
MEDICAL RELEASE
FORM FOR YOUNG WOMEN SUMMER CAMP 2015
Are you covered by medical
insurance? (please circle one) YES
NO
INSURANCE COMPANY:
______________________________Policy or ID#________________________
Group # (if have one)
_______________ Member Services Phone #: _________________________________
Name of Insured:
__________________________________ Insured’s Social Security # __________________
Employer : ______________________________________________
Family Physician:
__________________________________________________Phone # ________________
Medical
Information – Explain below and use back if more space is needed.
Special Diet requires you provide
your own food. Special arrangements can
be made & the camp kitchen may be used.
Chronic or recurring illness of
participant: ______________________________________________________________
Allergies: __________________________________________________________________________
Physical conditions that limit activity: __________________________________________________________________________________
Physical conditions that limit activity: __________________________________________________________________________________
Medications (MUST be stored and administered at the Nurse’s Station):
Please Initial
one:
Camp staff may
_____ may not _____ administer over-the-counter (OTC) medications. Medications
NOT to be given:
NOT to be given:
I give permission for my youth to
participate in the activity listed above and authorize the adult leaders supervising
this activity 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 activity and travel to and from this activity.
Signature of Parent or Guardian
_________________________________ Date ___________________
Bishop
Signature_____________________________________________ Date ___________________
