Participant Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Cell Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact CELL Phone *

(###)

###

####

Emergency Contact OTHER Phone

(###)

###

####

DIET: Does the participant require a special diet? *

Yes

No

ALLERGIES: Does the participant have any allergies? *

Yes

No

OTC DRUGS: Is the participant taking any medication or over-the-counter (OTC) drugs? *

Yes

No

OTC DRUGS: If yes, can the participant self-administer his or her medication?

If no, please contact a member of the Stake YM or YW Presidency.

Yes

No

ILLNESS: Does the participant have a chronic or recurring illness? *

Yes

No

PAST YEAR: Has the participant had surgery or a serious illness in the past year? *

Yes

No

Approved Medications *

Please list the medications that can be given during the week.

Ibuprofen (Advil, Motrin)

Tums

Acetaminophen

Mylanta

Benadryl

Calamine

Imodium

Sudafed

Cough Drops

Robitussin

Becitracin

Cortaid

Silvadene

Zanfel Wash

Bengay

NONE OF THE ABOVE