Consent and Authorization Form

West Jordan Utah Jordan Oaks Stake 5th Ward

Participant's Name Cell Phone

Address Date of Birth

Home Phone Parent's Cell phones

Consent and Authorization

I give my consent for the above-named person to participate in the activity programs of the
West Jordan Utah, Jordan Oaks Stake 5th Ward, including (describe activity):

Parent's Authorization (required for those under 18 years of age)

This health history is correct so far as I know, and the person herein described has permission
to engage in all prescribed activities, except as noted by me and the physician. In the event I
cannot be reached in an emergency, I hereby give permission to the physician selected by the
adult leader in charge to hospitalize, secure proper anesthesia, or to order injection or surgery
for my child.

Signature of Parent or Guardian Date

Medical Information (to be used if necessary):

Do you have or require any of the following (circle):

Yes No Special Diet

Yes No Allergies
Yes No Physical condition that would limit activity
Yes No Medication
Yes No chronic or recurring illness
Yes No have you had surgery or a serious illness in the past year

If the answer is “yes” to any of the above, give a full explanation of each on the back.