LDS Permission Form – Fill Out and Use This PDF

THE CHURCH OF

Permission and Medical Release Form

I

OF LATTER-DAY SAINTS

JESUS CHRIST

Event Details (to be filled out by event planner)

Event

Date(s) of event

Describe event and activities (please be specific)

Ward

Stake

Event or activity leader

Event or activity leader’s phone number

Event or activity leader’s email

Participant

Date of birth

Age

Primary telephone number

□ Home

Secondary telephone number

□ Home

□ Cell □ Work

□ Cell □ Work

Address

City

State or province

Emergency contact (parent or guardian)

Primary telephone number

□ Home

Secondary telephone number

□ Home

□ Cell □ Work

□ Cell □ Work

Does the participant require a special diet?

If yes, please explain the dietary restrictions

□ Yes □ No

Does the participant have any allergies?

If yes, please list the allergies

□ Yes □ No

Is the participant taking any medication or over-the-counter (OTC) drugs?

If yes, can the participant self-administer his or her medication?

□ Yes □ No

□ Yes □ No If no, please contact the event or activity leader directly.

List all prescription or over-the-counter (OTC) medications the participant is taking

Does the participant have a chronic or recurring illness?

If yes, please explain

□ Yes □ No

Has the participant had surgery or a serious illness in the past year?

If yes, please explain

□ Yes □ No

Identify any other limits, restrictions, or disabilities that could prevent the participant from fully participating in the event or activity (attach additional pages if needed)