Parental Or Guardian Permission And Medical Release
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1Parental or Guardian Permission and Medical Release
Date
Activity
Pioneer Trek 2017
August 2-5 2017
Ward
Stake
Bountiful South Stake
Participant
Date of birth
Home telephone number
Participant’s parent or guardian
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
for any accident or illness and to act in my stead in approving nec-
listed above and authorize the adult leaders supervising this activity
essary medical care. This authorization shall cover this activity and
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
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Parent category: Legal