Leader Registration

Leader First Name

Leader Last Name

Address

City/Town

State

ZIP Code

Cell Number

Phone Number

T-shirt size

Select Ward/Branch

Years at Girls Camp

Position at Girls Camp

Days You will be at camp

Monday Tuesday Wednesday Thursday Friday Saterday

Emergency Contact

Emergency Contact Phone Number

Relationship

Adult General Information / Medial Form and Authorization

Allergies: Check those that apply:

I have NO KNOWN ALLERGIES

Are you allergic to or do you have any adverse reaction to any of the following?

Food(s):

Yes No

Medication(s):

Yes No

Plant(s):

Yes No

Insect bites/stings

Yes No

Chronic Health Concerns: Check those that pertain to this girl and describe how you handle this at home.

I have NO CHRONIC HEALTH CONCERNS and can participate in all activities without restrictions.

I have has the following chronic health concern(s):

Information about Chronic Health Concerns from above:

Immunization History:

Are immunizations up to date?

Yes No

Tetanus Booster Date

Please write in month and year of last dose given:

Medications:
Any substance a person takes to maintain and/or improve her health and includes vitamins or homeopathic remedies.

I will NOT take any daily medications while attending girl's camp.

I will take the following medications while at camp:

Number of Medications taken:

1 2 3 4

Many common over the counter medications will be available at camp including but not limited to:

Please check any medications you should NOT receive:

Physician & Medical Insurance:

Do you have Primary Care Physician?

Yes No

Are you covered by an insurance policy?

Yes No

Do you have any limitations or restrictions for physical activity?

Yes No

Have we forgotten to ask anything else?

Yes No

Authorization for Healthcare:

This health history is correct and accurately reflects the health status of the individual to which it pertains. I understand that participation in girl's camp involves a certain degree of risk. I release the camp leaders, camp nurses, and other volunteers from any and all claims or liability arising out of this participation. I give permission to the camp nurses to administer over-the-counter medications. I give permission for the camp nurses under the direction of a physician to treat this individual in case of an emergency - to do what is needed to stabilize the individual until emergency medical personnel arrive. I give permission to the camp staff to hospitalize, secure proper treatment for, and select a physician for this individual. I give permission to the physician to order injection, anesthesia and surgery for this individual. I understand information on this form will be shared on a "need to Know" basis. I give permission to photocopy this form. In addition, give permission to obtain copy of this individuals health record from providers who treat this individual and these providers may talk with the camp staff about this individuals health status.

By typing your name you are giving an electronic signature stating your agreement and authorization.

Signature

Date

Young Women Camp 2023

Adult General Information / Medial Form and Authorization

Authorization for Healthcare: