Parental Form - Boston Stake Youth

THINGS TO REMEMBER
Boston Stake Youth Conference 2015
July 9-11 2015
Lunch for first day
CLOTHES
Pajamas
Underwear
Socks
2 pair long pants
1 long sleeve shirt
Sweatshirt or jacket
Sneakers
2 Shorts--minimum inseam of 8”
2 Short sleeved shirts
Rain coat
LINENS
Sheets OR Sleeping Bag
Pillow
Towel
PERSONAL ITEMS
Comb or brush
Toothbrush and toothpaste
Personal toiletries
Soap and shampoo
OTHER
Scriptures and pen or pencil
Camera (optional)
Small, lightweight back pack (optional)
Bug Spray
Sunscreen
Water Bottle
RULES OF CONDUCT FOR BOSTON STAKE YOUTH CONFERENCE
1) I will maintain the standards of the Church of Jesus Christ of Latter-Day Saints in
my manner of dress, language and behavior while at Youth Conference.
2) I will respect the rights of others and treat them with consideration at all times.
This includes being in my room at lights out and not disturbing the personal belongings
of other youth or leaders.
3) I will participate in and contribute to making this year’s Youth Conference
experience an enjoyable one, both for myself and for others.
4) I will respect the property and grounds of the sites I visit, and will not deface or
harm them in any way.
I will abide by the standards encompassed in the Gospel of Jesus Christ and will:
• Be honest
• Be chaste and virtuous
• Obey the law
• Use clean language
• Respect others
• Abstain from alcoholic beverages, tobacco, tea, coffee and substance abuse
• Observe dress and grooming standards
• Encourage others in their commitment to comply with these standards
As a member of the Boston Massachusetts Stake, I acknowledge the standards of the
Church of Jesus Christ of Latter Day Saints as vital in providing an environment of
trust, order and unity. I freely abide by these standards in all aspects of my conduct.
_____________________________________
Signature of Young Woman or Young Man
Date
Parental or Guardian Permission and Medical Release
Date
Activity
Ward
Stake
Participant
Date of birth
Participant’s parent or guardian
Home telephone number
Business telephone number
Address
City
State/Province
Medical Information
Does the participant have any of the following:
! Special diet
! Allergies
! Medication
! Chronic/Recurring illness
! Surgery or a serious illness in the past year
! Physical conditions that limit activity
If yes, explain below. Use back if more space is needed.
I give permission for my child/youth to participate in the activity
listed above and authorize the adult leaders supervising this activity
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 activity and
travel to and from this activity.
Parent or guardian’s signature
Date
6/98. Printed in the USA. 33810
GENERAL INFORMATION FOR PARENTS
1)
Parental or Guardian Permission and Medical Release
Date
Youth are responsibleActivity
for completing Youth Conference Registration online
by June 1, 2015.
Ward
2)
Stake
Youth Code of Conduct form must be signed and returned to the Stake Young Men’s Secretary,
Derek Hable, by July 1, 2015.
Participant
Date of birth
Home telephone number
parent or guardian
Business telephone number
3)Participant’s
Parental Consent/Medical Release form must be signed and returned to the Stake Young Men’s
Secretary, Derek Hable, by July 1, 2015.
Address
City
State/Province
4)MedicalIfInformation
my child is found to be unable to comply with the rules of conduct or is found to be a
Does the participant have any of the following:
disruptive
influence
to!the
purpose
of Youth Conference,
I understand that I will! be
obligated to come
! Special diet
! Allergies
Medication
! Chronic/Recurring illness
! Surgery or a serious illness in the past year
Physical conditions that limit activity
and
get
him/her
from
Palmyra
at the time of my notification.
If yes,
explain
below. Use back
if more
space is needed.
___________________________________
Signature of Parent/Guardian
I give permission for my child/youth to participate in the activity
Date
for any accident or illness and to act in my stead in approving nec-
Bylisted
signing
this
paper,
we the
signify
we supervising
understand
the
information
and
will
support the
Youth
above
and
authorize
adultthat
leaders
this
activity
essarypresented
medical care.
This
authorization
shall
coverConference
this activity and
Leaders'
decisions
concerning
consequences
for
failure
to
comply
with
them.
to administer emergency treatment to the above-named participant
travel to and from this activity.
Parent or guardian’s signature
Date
6/98. Printed in the USA. 33810
PERSONAL INFORMATION FORM
Part A: Personal Information (Parent must complete)
Name _____________________________Date of Birth ______________________Age__________
Name of Parent or Guardian #1__________________________________________
Phone (W)____________ Phone (H)____________ Cell/Other phone ____________________
Home Address______________________________City_______________ State_____ Zip
______________
If the above named person is not available in the event of an emergency, notify:
Name
________________________________Relationship:______________Phone___________________
Name
________________________________Relationship:______________Phone___________________
Name of Personal Physician _________________________________
Phone__________________________
Physician’s Address __________________________City________________State______Zip
_____________
Personal Health/Accident Insurance Carrier______________________ Policy
#________________________
Check all items that apply, past or present to your health history. Explain any “Yes” answers
Allergies: Yes No
List and type of reaction: ____________________________________
List any physical or behavioral conditions that may affect or limit full participation in swimming, hiking,
or playing strenuous physical games:
________________________________________________________________________________
Boston Stake Youth Conference Nurse’s Form - 2015
List equipment needed such as glasses, contact lenses, crutches, knee braces, etc.
________________________________________________________________________________
Any additional physical or emotional information that will assist us in caring for your child:
________________________________________________________________________________
________________________________________________________________________________
Part B: Permission to treat/ Over the Counter Medications: (Parent must complete)
I _____________________ (parent)
give □
do not give □
the Youth Conference health officer permission to administer over the counter medications. These
would include but may not be limited to Tylenol, Advil, or Benadryl. Medications indicated under the
allergies section of this form will not be administered.
In case of emergency, I understand every effort will be made to contact me. In the event I
cannot be reached, I hereby give my permission to the physician selected by the adult leader
in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or
injections of medication for my child.
Date_______________ Signature of Parent or Guardian ___________________________
THE FOLLOWING PAGE (Part C), NEED ONLY BE COMPLETED IF YOUR CHILD NEEDS
PRESCRIPTION MEDICATIONS WHILE AT YOUTH CONFERENCE. IF YOU DO NOT NEED TO
USE THE LAST PAGE, PLEASE DISCARD.
Boston Stake Youth Conference Nurse's Form - 2015
Part C: Prescription Medications: (Parent and Physician must complete)
This section must be completed by the physician ONLY if prescription medications will be
administered during Youth Conference.
Please copy this page if more space is needed.
Medication must be in the original container.
Medication #1: _________________________ Prescription Number: _______________
Dosage: ____________________ Frequency: _______________ Time: _____________
Condition requiring medication: _____________________________________________
Common side effects of medication:__________________________________________
Medication #2: _________________________ Prescription Number: _______________
Dosage: ____________________ Frequency: _______________ Time: _____________
Condition requiring medication: _____________________________________________
Common side effects of medication:__________________________________________
Medication #3: _________________________ Prescription Number: _______________
Dosage: ____________________ Frequency: _______________ Time: _____________
Condition requiring medication: _____________________________________________
Common side effects of medication:__________________________________________
I authorize the health officer to administer the medication as indicated above by
the physician.
Date: ________ Signature of parent or guardian:_________________________________
Date: ____________________ Signature of Physician: ___________________________