Youth Registration

Young Women Camp 2023

Young Women's First Name *

Young Women's Middle Name

Young Women's Last Name *

YW Birth Date (mm/dd/yyyy) *

YW Age *

Select Camp Year *

Select ward/branch *

Address *

City/Town *

State *

ZIP Code *

Young Women's # (Cell)

Young Women's Email

T-shirt size *

YW School Year *

School Attending *

Most Looking Forward To:

Let us know what excites you about camp this year!

Kind of Nervous About:

Parent/Guardians Full Name *

Relationship to Young Women *

Parents/Guardians Phone # - Primary *

Parents/Guardians Phone # - Secondary

Parent/Guardians Email *

Parent/Guardians Full Name

Relationship to Young Women

Parents/Guardians Phone # - Primary

Parents/Guardians Phone # - Secondary

Parent/Guardians Email

Young Women's General Information / Medial Form and Authorization

Height (inches): *

Weight (lbs): *

Allergies: Check those that apply:

Alergy_all

This girl has 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

Plants *

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.

chc1

This girl has NO CHRONIC HEALTH CONCERNS and can participate in all activities without restrictions.

This girl has the following chronic health concern(s):

chc3

Diabetes

Hypertension (high blood pressure)

Heart Conditions

Asthma

Lung/respiratory disease

COPD

Ear/eyes/nose/sinus problems

Seasonal Allergies

Head injury/concussion

Psychiatric/psychological or emotional difficulties

Behavioral/neurological disorders

Seizure Disorder

Blood disorders/sickle cell disease

Fainting spells and dizziness

Kidney disease

Sleepwalking

Glasses or Contacts

Headaches

Menstrual Cramps

Thyroid disease

Obstructive sleep apnea/sleep disorders

Other (Describe Below)

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.

med2

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

My child will take the following medications while at camp:

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

Please check any medications your child should NOT receive:

medCheck

Acetaminophen (Tylenol)

Calamine Lotion

Pepto-Bismol

Diphenhydramine (Benadryl)

Guaifenesin DM (cough syrup)

Ibuprofen

Cough Drops

Triple Antibiotic Cream

Tums

Pseudoephedrine

Aloe Vera Gel

Burn Cream

Sun Screen

Cortisone Creame

Benadryl Ointment

Imodium

Carmex

If Other please list:

Physician & Medical Insurance:

Does Child have Primary Care Physician?

Yes No

Is your child covered by an insurance policy?

Yes No

Does Your daughter have any limitations or restrictions for physical activity? *

Yes No

Have we forgotten to ask anything else? *

Yes No

Parent/Guardian Authorization for Healthcare:

This health history is correct and accurately reflects the health status of the child to which it pertains. I understand that participation in girl's camp involves a certain degree of risk. I have considered these risks and give permission for my daughter to participate in all camp activities except as noted above. 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 my child in case of an emergency - to do what is needed to stabilize the child until emergency medical personnel arrive. If I cannot be reached in an emergency, I give permission to the camp staff to hospitalize, secure proper treatment for, and select a physician for my child. I give permission to the physician to order injection, anesthesia and surgery for this child. 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 my child's health record from providers who treat my child and these providers may talk with the camp staff about my child's health status.

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

Parent/Guardian Name *

Date *

Relationship to Young Women *