Camper's Name *

First Name

Last Name

Camper's Birth Date *

MM

DD

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Camper Cell Number *

If camper does not have a cell phone, please give the number for the most direct way to get ahold of them.

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Camper's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian's Cell Number *

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Transportation Policy *

We expect all young women to come to Camp with their ward or individually by car or by van. YW are expected to respect their adult leaders while traveling. Camp Staff will make every effort to ensure the safety and comfort of each Camper. However, parents are expected to be available to arrange the transport of their daughter home in the event of an illness, emergency, or if she is asked to leave camp.

Yes, as a PARTICIPANT, I agree to follow the above Transportation Policy.‎

Yes, as a PARENT/GUARDIAN, I agree to follow the above Transportation Policy.‎

Medical Release and Parent/Guardian Acceptance *

I, the undersigned parent/guardian of the named participant on this registration form, a minor, do hereby authorize Oakland California Stake adult leaders as agent(s) of the undersigned to consent to any x-ray, examination, anesthesia, medical or surgical diagnosis or treatment and hospital care which is deemed to be advisable by and is to be rendered under the general or special supervision of any accredited physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any accredited hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. This authorization is given pursuant to provisions of Section 6910 of the Family Code of California. I hereby authorize any hospital, which has provided treatment to the above named minor, to release the minor to said agent(s) upon the completion of treatment. I understand that every attempt will be made to contact me in case of an emergency. This authorization shall remain in effect from July 4, 2022 through July 10, 2022 unless sooner revoked in writing delivered to said person. I am also willing to come pick up my daughter in the event she is deemed ill by her Girls Camp leaders.

Yes, as a PARENT/GUARDIAN, I agree with the above Medical Release statement.

Activity Release *

I also give permission for my daughter to participate in all Young Women Camp activities, including but not limited to swimming, water activities, rappelling, archery and BB gun use. She is physically and mentally able to do so and agrees to abide by the set dress standards, swimming attire, waterfront, BB gun and archery range safety guidelines.

Yes, as a PARENT/GUARDIAN, I agree with the Activity Release.

Signed by Parent or Guardian's Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Primary Insured *

First Name

Last Name

Doctor's Phone Number *

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Emergency Contact 1 *

First Name

Last Name

Emergency Contact 1's Phone Number *

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Emergency Contact 2 *

First Name

Last Name

Emergency Contact 2's Phone Number *

(###)

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Date of Last Tetanus Shot

Must be within the last 10 years

MM

DD

YYYY

Please check any that apply to the camper

Back Problems‎

Chronic Illness‎

Depression‎

Diabetes‎

Dizziness‎

Drug allergies‎

Ear Infections‎

Eating Disorders‎

Epilepsy/Seizures‎

Eye Problems‎

Fainting‎

Food Allergies‎

Hay Fever‎

Headaches‎

Heart Trouble‎

High Blood Pressure‎

Irritable Bowel Syndrome‎

Lung Disease‎

Menstrual Problems‎

Nose Bleeds‎

Other Allergies‎

Physical Disabilities‎

Psychological Disorders‎

Recent Injury‎

Recent Serious Illness‎

Recent Surgery‎

Rheumatic Fever‎

Severe Reaction to Poison Oak‎

Sleep Walking‎

Sore Throat‎

Stomach Problems‎

Anxiety or ADHD‎

Please indicate which over the counter medications we should NOT give your daughter

Tylenol for minor pain or fever‎

Ibuprofen for minor pain or fever‎

Triaminic for stuffy nose‎

Benadryl for allergic reaction‎

Antacids‎

Pepto Bismol for stomach upset‎

Laxative for constipation‎

Imodium for diarrhea‎

Throat Lozenges - for sore throat‎

Cold Remedies - decongestant‎

Cough Syrup‎

Expectorant‎

Childhood Immunization Record - NEW THIS YEAR: Required *

Please email pictures or scans of camper's immunization record to oaklandywcamp@gmail.com.

Done

Parent/Guardian (adult) Authorization *

This health history is correct so far as I know, and the person herein described has my permission to engage in ALL prescribed camp activities, EXCEPT as noted above by me. I also understand that I am responsible to pick up my daughter from camp should she become ill.

Yes, as a PARENT/GUARDIAN, I agree to the above Parent Authorization Statement.

Signed by Parent/Guardian's Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Mobile Phone Policy *

All mobile phones must be in airplane mode and not be used for anything besides taking pictures. No phone charging will be allowed, although extra external batteries can be used (but cannot be charged while at camp). Of course, you may text or phone parents to arrange rides at the end of the day.

Yes, as a PARTICIPANT, I agree to follow the Mobile Phone Policy

Honor Code *

Be honest. Use the buddy system. Respect the privacy of others and leave their possessions alone. Cooperate with leaders. Participate in service and all activities. Be a friend and example. Abide by the "For the Strength of Youth" guidelines (no smoking, drinking, drugs, use appropriate language and dress). Leave camp better than you found it.

Yes, as a PARTICIPANT, I agree to follow the Camp Honor Code

Pledge of Cooperation *

I agree to abide by all camp rules and instructions, both in letter and spirit. I agree not to leave camp. Should I be on a hike or expedition beyond the boundaries of the camp, I agree to stay with the leader of the group and under her supervision at all times. I will participate in this camping experience with an attitude of good sportsmanship and good faith, and I will contribute wholeheartedly of my friendship and enthusiasm, talents, and cooperation that this may be a choice experience for all concerned. I will honestly fulfill my assigned camp duties. Should any unforeseen difficulty arise, I will counsel at once with leaders in a spirit of love and friendship.

Yes, as a PARTICIPANT, I agree to the Pledge of Cooperation

Dress Code *

Respectful, uniform dress is a relief to all, a break for everybody from the body image rat race. Extremes in dress are distracting to all concerned, detract from the spirit of unity we are trying to foster, and introduce a spirit of competition amongst the group. Please dress in a way that is respectful of the collective goal of nurturing our testimony of Christ through adventure, activities, learning, and friendship.

Yes, as a PARTICIPANT, I agree to follow the Dress Code

Parent/Guardian Support Statement and Photo Consent *

I give my consent for the above named camper to participate in the Oakland, California, Young Women Camp. I have read and reviewed the camp policies, as well as the pledge of cooperation with my daughter. I understand that should the camper be found to have violated any of these conditions by the leaders of the camp, she may be sent home at my expense or my personal transportation. I release all Young Women leaders and personnel of said camp from any responsibility for any injury or illness sustained while traveling to and from camp and while participating in any camp activity or outing. I authorize my daughter's photo to be taken while participating in normal camp activities. These photos may be posted on the camp website.

Yes, as a PARENT/GUARDIAN, I agree to support my daughter and authorize her photo to be taken during normal camp activities.

Signed by Parent/Guardian's Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY