Permission and Medical Release Form

Each participant (including leaders) completes this form separately for each event or activity involving an overnight stay, travel outside the local area, or higher than ordinary risks (see General Handbook: Serving in The Church of Jesus Christ of Latter-day Saints, 20.5.5, 20.7.4, 20.7.7). The event or activity leader should have access to all participants forms during the activity.

NOTE: Greyed out fields cannot be changed as they are populated automatically.

Event Details Event:

Date(s) of Event:
Describe Event and Activities:
Event or Activity Leader:
Event or Activity Leaders Phone Number:
Event or Activity Leaders Email:
Are you a Member of the Winchester Virginia Stake?

Contact Information First name:
Last name:
Are you attending as Youth or as a Adult Leader? Telephone number:
Email:
Date of birth:
Age:

T-shirt size:

Address:
City:
State: Emergency contact:
Relationship:
Primary telephone number:
Secondary telephone number:

Medical Information Does the participant have any special dietary requirements?
Do you have any allergies?
List all prescription or over-the-counter (OTC) medications the participant is taking (leave blank if none):
Can the participant self-administer his or her medication?

Conditions That Limit Activity Does the participant have a chronic or recurring illness?
Has the participant had surgery or a serious illness in the past year?
Identify any other limits, restrictions, or disabilities:

Other Accommodations or Special Needs Identify any other needs or considerations:

Signature

NOTE: A parent or legal guardian MUST sign the registration unless you are 18 when completing this registration..

I give permission for my child or youth to participate in the event and activities listed above (unless noted) and authorize the adult leaders supervising this event 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 event and travel to and from this event.

Parents and participants should understand that participation in an activity is not a right but a privilege that can be revoked if participants behave inappropriately or if they pose a risk to themselves or others.

This information is collected to help event and activity leaders or medical personnel so they can be prepared and appropriately respond to health concerns or an emergency. It will be kept confidential and shared only as needed.

I agree
Parent or guardian's signature (if participant is a minor):