2022 Mclean Virginia Stake Youth Conference "Building Trust in the Lord"

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Palmyra, New York
June 23-25, 2022
Those turning 14 in 2022, or older, are invited to attend.

Email *

Youth / Adult Leader *

Name

Last *

First *

Middle

Date of Birth (required for youth, optional for adult leader)

YYYY

Sex *

Ward *

Roommate Preference, if any (up to three names). We will try to accommodate preferences but cannot guarantee them.

Home Address

Street *

City *

Zip Code *

Home Telephone Number *

Cell Phone Number *

Emergency Contact Information

Name *

Address *

Email *

Cell Phone *

Relationship *

Medical Information

Insurance Company *

Policy Number *

Doctor *

Doctor's Telephone *

Health Information: Please list all medical issues including allergies (food, medications, bee stings, etc.), physical restrictions or conditions requiring regular medications. Please include a list of all medications with the dosage and time/frequency to be taken. Do any medications require refrigeration? (Y/N) *

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