Bloomington Hills Stake Youth
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Upcoming Events
Young Men/Women Theme
Home
Upcoming Events
Young Men/Women Theme
Bloomington Hills Stake Youth
Register Here
Stake Girls Camp
Participant Name
*
First Name
Last Name
Ward
*
1st
2nd
3rd
4th
5th
6th
8th
10th
Birthday
*
MM
DD
YYYY
Participants Age by 6/1/22
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
*
Name of Parent Legal Guardian
*
First Name
Last Name
Parent/Legal Guardian Phone
*
(###)
###
####
Parent/Legal Guardian Email
*
First Name
Last Name
Parent/Legal Guardian Name
First Name
Last Name
Parent/Legal Guardian Email
Name of Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Does the participant require a special diet
*
Yes
No
If yes please explain the dietary restrictions
Does the participant have any allergies
*
Yes
No
If yes please list the allergies
Is the participant taking any medication or overthecounter OTC drugs
*
yes
no
If yes can the participant self administer his or her medication If no please contact the event or activity leader directly
*
yes
no
N/A
List all prescription or overthecounter OTC medications the participant is taking
Does the participant have a chronic or recurring illness
*
yes
no
If yes please explain
Has the participant had surgery or a serious illness in the past year
*
yes
no
If yes please explain
Identify any other limits restrictions or disabilities that could prevent the participant from fully participating in the event or activity
Identify any other needs or considerations the participant has that the event or activity planner should be aware of
I give permission for my child or youth to participate in the Bloomington Hills Stake Youth Trek June 24 2022 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
*
yes
no
The participant has reviewed the behavioral guidelines dress and grooming standards and other rules regarding participation in this Youth Trek Does the participant understand what will be required of him her during their participation in this trek
*
yes
no
As an adult leader parent or guardian I have reviewed the participationbehavioral guidelines and understand that adherence to the standards is required of all participants
*
yes
no
As an adult leader or the parentlegal guardian of a youth participant I acknowledge that I will be financially responsible for any property damage incurred by myselfor by my son or daughter during this Youth Trek
*
yes
no
I understand that if any participant youth or leader fails to comply with required participationbehavioral guidelines he or she may be sent home at their own expense
*
yes
no
By participating in the 2022 Bloomington Hills Youth Trek I consent that my or my childs image may be used for the creation of memorabilia andor uploaded to stake social media sites as needed
*
yes
no
Full Name of Parent/Legal Guardian completing this form
*
First Name
Last Name
I agree that this serves as my digital signature
*
TRUE
FALSE
Name of Youth Participant completing this form
*
First Name
Last Name
I agree that this serves as my digital signature
*
TRUE
FALSE
Thank you!