Registration and Permission Form / Medical Release

Participant name *

First Name

Last Name

Birth date *

MM

DD

YYYY

Emergency contact (parent or guardian) *

First Name

Last Name

Primary telephone number *

(###)

###

####

Primary number type *

Home

Mobile

Work

Secondary telephone number *

(###)

###

####

Secondary number type *

Home

Mobile

Work

Does the participant require a special diet? *

Yes

No

Does the participant have any allergies? *

Yes

No

Is the participant taking any medication or over-the-counter (OTC) drugs? *

Yes

No

If yes, can the participant self-administer the medication?

If participant cannot self-administer, please contact Brother Barker or Brother Smith directly.

Yes

No

Does the participant have a chronic or recurring illness? *

Yes

No

Has the participant had surgery or a serious illness in the past year? *

Yes

No

Photo/video release *

Do we have your permission to include you in photos or videos for use on the stake youth website (seanorthyouth.org) or for fireside presentations after camp?

Yes

No