PARENTAL OR GUARDIAN PERMISSION AND MEDICAL RELEASE FORM BRANDON STAKE YOUNG WOMEN'S CAMP 2011 April 25 - 29, 2011 Participant's Name:__________________________________________________________________ Camp Level: Level 1 (age 12) / Level 2 (age 13) / Level 3 (age 14) / Level 4 (age 15) / YCL (Age 16-17) Ward:____________________________ Birthdate: ________________________________________ Address:___________________________________________________________________________ City: __________________________ Zip: ___________ Phone: _____________________________ Have you received your Young Womanhood Recognition Award: Adult t-shirt size (circle one): S M L XL yes______ XXL no_____

Parent/Guardian/ Emergency Contact:___________________________________________________ Address: __________________________________________________________________________ Emergency Phone Contact: ( Health Insurance: Yes ______ ) _____________________ ( ) _____________________

No______ (Please attach a copy of the front and back side of the card.)

Name of Insurance Carrier: ______________________________Policy # ______________________ Do you have any of the following (If yes, please explain below): N/A_________ _____ Special Diet _____ Chronic Recurring Illness _____ Allergies _____ Medications _____ Physical Conditions that limit activity _____FOOD Allergies _____ Surgery or serious illness in the past year _______________________________________________________ _______________________________________________________


I give permission for ____________________________________ to participate in the Brandon Stake Young Women's Camp and ALL associated activities. I authorize the adult leaders supervising these activities to administer emergency treatment for any accident or illness, and to act in my stead in approving necessary medical care. This authorization shall cover all activities during camp and include travel to and from and during camp. Signature of Parent/Guardian: __________________________________ Date: ________________

Subscribed and sworn to before me this ________ day of ______________________________, 2011

___________________________________ Notary Public


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