Adult Leader Name *

First Name

Last Name

Home Phone

(###)

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Cell Phone *

(###)

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Birthday *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical Release *

I, the undersigned, do hereby authorize Oakland, California Stake adult leaders as my agent(s), in the event of my incapacitation, 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. Further, I do hereby expressly consent that I may receive emergency medical treatment from any physician, hospital, or other medical center. I do release, acquit, discharge, and covenant to hold harmless Oakland, California Stake and its adult leaders from any and all actions, damages, and liabilities arising out of the treatment of any sickness or accident incurred by me at Young Women Camp. I hereby authorize any hospital, which has provided me with treatment, to release me to said agent(s) upon the completion of treatment. I understand that every attempt will be made to reach my emergency contact as provided above, in case of an emergency. This authorization shall remain in effect from July 4, 2022 to July 10, 2022, unless sooner revoked in writing delivered to said person.

Yes, I agree to the above medical release.

Signed by *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Primary Insured *

First Name

Last Name

Primary Doctor *

First Name

Last Name

Primary Doctor's Phone *

(###)

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Emergency Contact 1 *

First Name

Last Name

Emergency Contact 1's Phone *

(###)

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Emergency Contact 2 *

First Name

Last Name

Emergency Contact 2's Phone *

(###)

###

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Date of Last Tetanus Shot

Must be less than 10 years ago

MM

DD

YYYY

Immunization Record *

New in 2022, as required by Nevada County CA. Please email pictures or scans of your lifetime immunization record, all pertinent pages, to oaklandywcamp@gmail.com. Go back in time as far as you reasonably can. Many of us have no records of our childhood vaccinations - that's okay!

Done

Working on it

CPR/First Aid Certification

New in 2022, as required by Nevada County CA, CPR and First Aid certification is required for ALL leaders at camp who have direct, sustained interaction with the youth. That is interpreted to mean all female year level leaders, and male leaders who are going on the hikes. Camp Directors, kitchen staff, crafts leaders, capers leaders, and priesthood leaders who are exclusively men-in-camp are not required to be certified. If you are already certified, or after you complete your certification, please email certificates of completion to oaklandywcamp@gmail.com. Further information on the best way to get certified will be emailed to leaders in the future.

I have a current certification and have emailed the certificate to oaklandywcamp@gmail.com

Working on it/waiting for more instructions

Adult Authorization *

This health history is correct as far as I know, and I am able to engage in ALL prescribed camp activities, EXCEPT as noted by me. I understand that I will be held responsible for any medications I bring into camp. I also understand that I may not share ANY medications I bring to camp with ANY of the young women.

Yes, I agree to the above Adult Authorization Statement

Photo Release and Authorization *

I agree that my photo may be taken while enjoying normal camp activities and shared at the camp fireside and on the Oakland YW Camp website.

Yes, I agree to the above Photo Release and Authorization Statement

Signed by *

First Name

Last Name

Today's Date *

MM

DD

YYYY