FSY Kickoff Registration January 20 2024

All youth turning 14 in 2024 up to 18. All youth and leaders planning to attend need to fill out the form below. Please list any food allergies as well.

This FSY Kickoff will be held at the QC North Stake Center.

Statement of Responsibility

Each participant must act in accordance with Church standards at all times and help others to do the same. As with all activities, there are inherent risks involved which are beyond the control of the property owners and stake leaders. All participants must act in a way not to endanger themselves or others and should show charitable consideration to all other participants and leaders at the FSY Kickoff.

Participant Name

First Name

Last Name

Participant Email Address

Participant Phone

(###)

###

####

Participant Date of Birth

YYYY

Gender

Ward

Address

City

Emergency Contact Info

Emergency Contact Name

First Name

Last Name

Emergency Contact Cell Phone

(###)

###

####

Emergency Contact Work Phone

(###)

###

####

Emergency Contact Home Phone

(###)

###

####

Emergency Contact Email

Emergency Contact Relationship to Participant

Medical Information

Allergies

Does the participant have any allergies? If yes, please list the allergies.

Medication

Is the participant taking any medication or over-the-counter (OTC) drugs? If yes, can the participant self-administer his or her medication? List all prescription or over-the-counter (OTC) medications the participant is taking.

Physical Conditions That Limit Activity

Chronic or Recurring Illness

Does the participant have a chronic or recurring illness? If yes, please explain.

Recent Surgery/Illness

Has the participant had surgery or a serious illness in the past year? If yes, please explain.

Other Limits, Restrictions, or Disabilities

Identify any other limits, restrictions, or disabilities that could prevent the participant from fully participating in the event or activity.

Other Accommodations or Special Needs

Other Needs

Identify any other needs or considerations the participant has that the event or activity planner should be aware of.

Permission

I give permission for my child/youth to participate in the event and activities listed above (unless noted) and authorize the adult leaders supervising this event to administer emergency treatment to the above-named participant for any accident or illness and to act in my stead in approving necessary medical care. This authorization shall cover this event and travel to and from this event. The participant is responsible for his or her own conduct and is aware of and agrees to abide by Church standards, camp, or event safety rules and other pertinent instructions. Participants’ conduct and interactions should abide by Church standards and exemplify Christlike behavior. Parents and participants should understand that participation in an activity is not a right but a privilege that can be revoked if they behave inappropriately or if they pose a risk to themselves or others.

I agree

I disagree

Parent or Guardian's Name

By entering your name into this field, you are legally signing this document.