Young Women 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= YW $180 (Early Bird Special $160 if paid by 4/3/11 with both registration & medical forms)

Camper’s Name __________________________________ Home Phone ( )_______________

Camper’s Age First Day of Camp _______ Grade in School ____ Camper’s cell # (____)_____________
Camper’s Email Address (please write clearly)_____________________________________________
THIS is my FIRST TIME at YW Camp Yes No Ward ______________________________
The LAST TIME I went to camp I was in Unit 1 2 3 4 High Adventure YCL
TH
(NEW THIS YEAR – ALL 5 YEAR GIRLS WILL BE IN HIGH ADVENTURE)
This year at camp I expect to be in Unit 1 2 3 4 High Adventure YCL
Camp shirt size: S M L XL 2X 3X
Swimming Level: Non Swimmer Beginner Intermediate/Advanced Lifeguard Certified

I expect to receive my YW Camp Tree this year: Yes No

(To receive a Tree you must have completed 5 years at YW Camp. At least 2 years must be at Treasure Mountain or Camp
Liahona Redwoods.)

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 already received my Liahona Tree: Yes No

Youth Camp Leader (YCL) Only

YCL Sweatshirt additional cost $20.00 ($30 if paid at camp) Yes No
SIZE: S M L XL 2X

YCL's - which unit would you like to help with?

1st Choice 2nd Choice 3rd Choice
Unit 1 2 3 4 Unit 1 2 3 4 Unit 1 2 3 4

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.”
♦ Camp Song is “Valiant Faith” by Jenny Phillips
♦ If a young woman turns 12 by December 1, 2011, she may go to camp.

DATES TO REMEMBER
March 3 Back to Camp Meeting 7 pm @ Napa Stake Center
March 27 Registration, Medical forms & Camp fees due to your Ward YW Leader
May 28-30 Camp Work Weekend
June 11 Unit 3 & 4 backpack check
June 13 Stake Staff & YCL’s 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. Please refer to the For the Strength of Youth pamphlet
♦ 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 bags and personal items
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, IPOD, DVD players, handheld games,
etc.
♦ Do not use cell phones at camp.
♦ Listen to and follow your leaders!!

PLEDGE OF COOPERATION
I agree to abide by all camp policies and instructions, both in letter and spirit. I agree never to leave camp without
permission or the companionship of a leader. Should I be on a hike or expedition beyond the boundaries of the camp, I agree to
stay with the leader of the group and under her supervision at all times, without exception.
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 my leaders in a spirit of love and friendship.

X________________________________________________ _________________
Signature of Young Woman Date

PARENTS SUPPORT STATEMENT

I have read the Camp Policies as well as the Pledge of Cooperation and have discussed them with my daughter. I
understand that should she be found to have violated any of these conditions, she may be sent home at my expense or via my
personal transportation.

X________________________________________________ _________________
Signature of Parent or Guardian Date

RULES FOR ACCEPTANCE AND PARTICIPATION IN THE PROGRAM ARE THE SAME FOR EVERYONE WITHOUT
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 _________________________________________ __________________________
 Unit _______
Young Women 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)___________________
Parent/Guardian ______________________Phone: Home_______________ Work ________________
EMERGENCY CONTACT, ________________ ______ PHONE____________________
(If parent/guardian not available)

Please check the box if the camper has or has had any of the following:
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 including
BRING TO CAMP Weak ankles, knees inhalers, vitamins, etc.
Fainting (bring ace bandages) _______________________
Chronic Sore Throats Back Problems _________________________
Chronic Nose Bleeds Recent Serious Illness _________________________
Headaches _____________________________ _________________________
Seizures Special Diet
Eye Problems _____________________________ ALL MEDICATIONS MUST COME
Ear Problems Allergic Reaction to Insect Stings TO CAMP IN THE ORIGINAL,
Hay fever _____________________________ LABELED CONTAINERS
Menstrual Problems Tetanus shot (Please provide the year - do not write current)
_______________________
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.

Parental or Guardian Permission and Medical Release

This health history is correct to the best of my knowledge, and the person described herein has my permission to
engage in all prescribed camp activities, except as noted above by me. I, the undersigned, parent/guardian of
_________________________________, 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 my minor daughter named above. This authorization shall cover this activity and travel to and from
this activity. This authorization shall remain in effect from June 13 through June 18, 2011, unless sooner revoked
in writing and delivered to said agents.

X_________________________________________________ ________________________________
Signature of parent/guardian 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: