Adult Leader Registration Form June 13 - 18, 2011

Napa Stake Young Women Camp DON’T MISS OUT ON A WEEK OF

27010 Skaggs Springs Road SPIRITUAL UPLIFTING AND
Annapolis, CA 95412-9704 AMAZING ADVENTURES!!

CAMP FEE- Adult Leader fee- $85 (Early Bird Special $75 if paid by 4/24/11 with both registration & medical forms
(Please Print)

NAME_________________ PHONE (____)_____________________

THIS is my FIRST TIME at YW Camp Yes No Ward _________________________

Which Unit would you prefer to be in? (Tent Leaders Only)

1st Choice 2nd Choice 3rd Choice
Unit 1 2 3 Unit 1 2 3 Unit 1 2 3

CAMP SHIRT SIZE: S M L XL 2X 3X

Swimming Level: Non Swimmer Beginner Intermediate/Advanced Lifeguard Certified

I expect to received my YW Camp Tree this year: Yes No
To receive a YW Camp Tree you must have completed 5 years at YW Camp.
At least 2 years must be at Treasure Mountain or the new camp.

I would like _ ______ __________or_____ ____________________ to present my

tree.
Must be someone who has already received her tree and she must be attending camp this year.

I have my Liahona Tree Yes No

YCL Leaders Only- Sweatshirt additional $20.00 Yes No SIZE: S M L XL 2X 3X

Please check the boxes if we can use your vehicle or if you are willing to drive someone else's vehicle

To/from camp At camp Drive someone else's vehicle Permission for others to drive your
vehicle

If any boxes are checked:

Drivers License #___________ __ ____4-Wheel Drive Yes No # of seat belts: ________

Ins. Carrier __ ___ ____________ ____ Policy #__ ________________

Vehicle Make _________________Model ______________ _____License #__ _____________

DATES TO REMEMBER
April 24 Adult Registration, Medical forms & Camp fees due to the Stake
May 5 Stake Staff Meeting - All Stake staff, tent leaders & YCL’s 6:30 pm @ Stake Center
May 28-30 Camp Work Week-end
June 5 Camp Temple Day 10:00 am session
June 9 Unit 3 & 4 backpack check
June 13 Stake Staff Unit 4 YW & YCLs Leave for camp
June 14-18 YOUNG WOMEN CAMP AT 27010 Skaggs Springs Rd, Annapolis, CA

Please make sure that this form is completely filled out. Incomplete forms will have to be returned to you for
completion. No registrations refunds will be given through the Stake and absolutely no registrations will be
accepted after June 1, 2011.

PLEASE COMPLETE REVERSE SIDE

CAMP POLICIES
♦ Follow Church standards.
♦ Dress Code:
Shorts - knee length
Pants - must be worn on hikes
Shirts - no sleeveless, no tank tops, no bare midriffs.
Swimsuits - one piece, modest
Shoes - only tennis, athletic or hiking boots (with shoelaces) worn with socks. We don’t want your
camp experience ruined by blisters and sore feet. Flip-flops are ok for shower use.
♦ Practice the “buddy system.” Be with a buddy at all times. Never leave the camp without an adult. Night
trips to the bathroom must be made with an adult or a Youth Leader.
♦ Families and friends are asked not to visit camp.
♦ This is varmint country, so please do not bring candy or gum to camp. We have had 3 new tents
destroyed in the past by chipmunks on a treasure hunt for candy in the tents.
♦ No electronic game, audio, or video devices. This includes radios, CDs, MP3 players, DVD players,
Handheld games, etc.
♦ Do not use cell phones at camp.
♦ Be an example!!

GENERAL INFORMATION
♦ Make checks payable to Napa Stake and give to a member of the Stake YW Presidency by April 29, 2010
♦ Our theme this year is ”Defenders of Faith”
♦ The value is Faith
♦ The color is White
♦ The scripture is 1 Timothy 6:12 “Fight the good fight of faith, lay hold on eternal life, whereunto thou
art also called, and hast professed a good profession before many witnesses.”
♦ If a young woman turns 12 by December 1, 2011, she may go to camp.

PLEDGE OF COOPERATION
I agree to abide by all camp policies and instructions, both in letter and spirit. If I have to leave camp I agree to first
check in at the office and follow the proper check-out procedures. I will participate in this camping experience with an attitude
of good sportsmanship and good faith, and I will contribute wholeheartedly of my friendship and enthusiasm, talents and
cooperation that this may be a choice experience for all concerned. I will honestly fulfill my assigned camp duties.
Should any unforeseen difficulty arise, I will counsel at once with the young women and leaders in a spirit of love and
friendship.

X________________________________________________ _________________
Adult Leader Date

Rules for acceptance and participation in the program are the same for everyone with out regard to
race, color, national origin, age, sex or handicap.
RELEASE OF LIABILITY

I, _______________________________, for and on behalf of ______________________________, a minor, do hereby

forever RELEASE AND DISCHARGE, the Church of Jesus Christ of Latter-day Saints and all agents and organizations
thereof, from any and all liabilities, claims, demands or causes of action which said minor may hereafter have for injuries,
loss, damages or death arising out of the said minor’s transportation to and from said activities and participation in swimming,
hiking, horseback riding, rock climbing, whitewater rafting, canoeing, boating, waterskiing, snorkeling, surfing, beach
activities, adventure sports and rappelling activities during YW Camp at YW Camp, June 13 - 18, 2011, including, but not
limited to losses, damages or death cause by the passive or active negligence of the released parties or by hidden, latent, or
obvious defects in the location of said swimming, hiking, horseback riding, rock climbing, whitewater rafting, canoeing,
boating, waterskiing, snorkeling, surfing, beach activities, adventure sports and rappelling or in the equipment used in that
activity.
I understand and acknowledge that hiking, swimming, horseback riding, rock climbing, whitewater rafting, canoeing,
boating, waterskiing, snorkeling, surfing, adventure sports, rappelling, beach activities and transportation to said activities
have inherent dangers which no amount of care, caution, instruction or expertise can eliminate and do expressly and
voluntarily assume all risk of injury, loss, damages or death which said minor may sustain as the result of said minor’s
participation in the above-described activities.
By my signature below I certify that I have read and that I understand the foregoing and that I have authority as the
parent or legal guardian of the minor described above to execute this release on her behalf.

X _________________________________________ __________________________
Signature of Adult Leader Date
 Unit _______
Adult Leader Medical Form
NAPA STAKE YOUNG WOMEN CAMP

Name_________________________________________________________Ward_ ____________
Address__________________________________ __ ___City _____________Zip___________

Phone # (___)______________________ Birth Date_________ _____ Age_______ HT______ WT_______

Cell # (___)____ ________________________ E-Mail_________________________________________

Doctor (or Kaiser Hospital) _______________________________Phone #____________________________

Medical Insurance Co. _______________ ______________ Policy # (Kaiser No)___________________

Spouse __________________________Phone: Home________________Work __________________

EMERGENCY CONTACT, (If spouse not available)__________________ ______PHONE___________________

Please check the box if you have or have had any of the following and check for head lice before coming to camp:
Diabetes Previous Surgery Allergies to Food or Meds
Insulin Dependent _____________________________ _________________________
Heart Disease _____________________________ _____________________ _
Hypertension Physical Disability _________________________
Lung Disease _____________________________
Asthma Recent Injury List Medications currently
Use Inhalers* _____________________________ taken on a routine basis
BRING TO CAMP including inhalers,vitamins, etc.
Weak ankles, knees
Fainting (bring ace bandages) ______________________
Chronic Sore Throats Back Problems _________________________
Chronic Nose Bleeds Recent Serious Illness _________________________
Headaches _____________________________ _________________________
Seizures Special Diet
Eye Problems _____________________________
/akdsfnmkdMF:MD fv ALL MEDICATIONS MUST COME
Ear Problems Allergic Reaction to Insect Stings TO CAMP IN THE ORIGINAL,
Hay fever _____________________________
Djfmg:Dmgv LABELED CONTAINERS
Menstrual Problems Tetanus shot (Please provide the year - do not write current)
_______________________
"LDSjfmj

Please explain on a separate piece of paper any suggestions or restrictions of activity including hiking and swimming.
*Please bring inhalers even if used only on an “as needed” basis.

MEDICAL CONSENT
This health history is correct to the best of my knowledge, and I am prepared to engage in all camp activities,
except as noted above. I, the undersigned, do hereby authorize the leaders of the Napa Stake Young Women
Camp as agents, to seek and obtain any medical treatment and hospital care deemed advisable by a licensed
practicing physician, for me. This authorization shall remain in effect from June 13-18, 2011, unless sooner
revoked in writing and delivered to said agents.

X____________________________________________________ ____________________________
Signature of Adult Leader Date

Blood Pressure_____________ Pulse Rate___________________

X_______________________________ ______________________
Signature of Examining Medical Personnel Date
 LDS YW Camp Individual Health Screening Record
To be completed within 24 hours of camp
Camper Name: Unit:
Date of Screening: Parent: Yes No = Who is:
Initials of
Receiving Desk: Required Treatment or Comments?
Screener
1. Medication collected?
(RX, OTC, Vitamins)
Meds No Meds

Are there changes from the prior forms?

Yes No
2. Ask about changes in health history
information since it was submitted.
(Parents may wish to review the health
history) Asked how they are feeling
now. Have they been seen by MD or
in the hospital recently?
Yes No
3. Ask about chicken pox, flu or other
communicable disease exposure in
previous 20 days. Visual check of
eyes/face for signs of colds/flu
Yes No
4. History of vomiting, diarrhea in last 3
days
Yes No
Health Exam:

Head: Check for fever. Look at the scalp Temperature _______________

for any cuts, rashes or evidence of head
lice.
Yes No

Throat: Check back of throat for redness,

tonsils for redness or yellow white spots,
canker sores, and ulcers throughout the
mouth.
Yes No

Skin: Check back of neck, front of neck,

and shoulder areas for rash, sores, and
scabs. Covered other skin: Check for
rash.
Yes No

Feet: Check between toes, heels, bottom,

and sides for rash, cracks and sores.
Yes No
Others:

Pass: YES NO

Signature of Health Examiner:

Signature of Health Examiner: