Saratoga Springs Utah North Stake
TREK Registration Form
TREK Date June 25-28, 2014
Due May 4, 2014
This form (2 pages) must be completed, signed in both places, and returned to your ward TREK Leader.Each participant (adult and youth) must complete a form. Ward TREK leaders must turn forms in
to the Stake liaisons.
Ward ____________________________
Name: ______________________________________Sex: ___ Age: ____ Birth date: ______________
Address: ____________________________________________________________________________
Height: __________ Weight: _______
Insurance Company: _________________________________ Policy #: _______________________
Parents' Name (if minor): _____________________________ Phone: ___________ Work: ________
Parents' Name (if minor): _____________________________ Phone: ___________ Work: ________
CONTRACT and RELEASE
1. I understand this Pioneer Trek 2014 will be held in a primitive wilderness setting. I also understand
although we will be "roughing it,” so to speak, that the Stake will provide food, restroom facilities,
and safe drinking water.
2. I am voluntarily a participant in this Trek and I will accept full responsibility for my actions under all
conditions. I also agree to aid other members of the group in behaving responsibly.
I understand and appreciate that there are inherent risks involved in this Stake-sponsored Trek which
are beyond the control of the Stake staff and Ward leaders, and I agree to personally assume such
risks. Also, the Stake staff and Ward leaders cannot be held responsible for any injuries or expenses,
costs and/or claims in connection with any injuries sustained which were not directly caused by their
failure to take due care. I hereby also agree to release the Saratoga Springs Utah North Stake and its staff and Ward leaders from any and all claims for liability arising from my participation in the Pioneer Trek 2014.
3. I agree to abide by LDS standards, including those outlined in For the Strength of Youth. This means high standards of behavior, honor and integrity; and abstinence from alcohol, tobacco and harmful drugs are required of me and every participant involved in this Trek.
4. I (and/or my guardian) agree to accept full responsibility for any medical or related expense incurred
which are not covered by my own insurance policy. Medical and dental benefits from the Church
Activity Insurance Program may be available, but they are secondary to other insurance coverage and
subject to limitations. Contact your bishop or branch president for plan coverage or a benefit claim
form in case of an accident. Please list any other required information that may be needed for insurance purposes if it becomes necessary to secure the medical services of a doctor or hospital. This could include insurance preauthorization phone numbers, name and Social Security number of the insured employee, whether it is necessary to contact a primary care physician, etc. Note: Parents of youth will be contacted, if at all possible, before securing the medical services of a doctor or hospital in the case of an emergency.
Information:
Each participant should condition themselves physically for this experience. Specifically, each
participant must be able to complete a minimum requirement of walking/running four(4) miles on level
ground in 60 minutes or less without undue stress.
Medical History
If you currently suffer from, or have experienced any of the following conditions within the past year,
please mark the appropriate space below:
___ Arthritis ___ Asthma (serious case)
___ Epilepsy ___ Emotional problems requiring medication
___ Fainting spells ___ Ulcers
___ Rheumatic fever ___ Major bone or joint injuries aggravated by hiking ___ High blood pressure ___ Major operation or serious illness
___ Hypoglycemia ___Heart trouble
___ Diabetes
____ Other medical conditions which could be aggravated by prolonged physical activity
Explain: __________________________________________________________________________________________
If you marked any of the above items, you must fill out the Medical Release Form and have it completed by a medical doctor; you cannot participate without it. The Medical Release Form is available from your ward TREK leaders.
Allergies, special diets, or medication reactions: ___________________________________________________________
Medications currently being used:______________________________________________________________________
Are immunizations up to date? _________yes ________no
Physical conditions that limit activity:___________________________________________________________________
Have you had more than a minor illness or injury during the year, or a chronic/recurring illness?
If yes, please explain:_______________________________________________________________________________
Family Doctor:__________________________________________Phone:_____________________________________
Participant Agreement
I agree to the above terms and declare the above statements are complete and correct, and agree to act in accordance with the Statement of Responsibility.
Signature of Participant:___________________________________________ Date: ______________
Parental Permission
I, the undersigned, am aware that my youth will be participating in the above designated Stake Pioneer
Trek Youth Conference. I have read the Statement of Responsibility and have supplied the medical
statements above, which are complete and correct. I hereby give my full permission for him/her to
participate in this youth conference and authorize the adult leaders supervising this activity to administer
emergency treatment for any accident or illness and to act in my stead in approving necessary medical
care in the event any medical attention is needed. I hereby authorize any physicians in charge of my child
to administer such medical or surgical treatment or carry out such procedure as may be deemed necessary
or advisable in the diagnosis or treatment of my child. This permission includes travel to and from the
conference as well as participation at the conference.
Signature of Parent / Guardian: ______________________________________ Date: ______________
(Parent or Guardian must sign here if participant is under 18 years of age.
Participants 18 or older must sign here –for themselves)
Saratoga Springs Utah North Stake TREK 2014
MEDICAL RELEASE FORM
Due May 4, 2014
This form must be completed and signed by a medical doctor for participants who answered “yes” to anyof the conditions listed on the Medical History portion of the Registration form. They will not be allowed to participate if this form is not submitted. The examination must be current within six months of the participation date (June 25, 2014) by a doctor.
Participant:_________________________________ Date of Conference: June 25-28, 2014
Dear Doctor: The above named person will participate in a Pioneer Youth Conference. Persons suffering
from any of the conditions listed below must obtain a physician’s clearance before participating in this
program. The participants will be in a wilderness setting for four days. They will have ample food and
water. They will hike/walk approximately 15 to 20 miles on varying terrain while pushing / pulling pioneer handcarts with a group of other participants and engage in other physical outdoor activities over a 4 day event.
Please consider the following conditions in your decision (as well as other medical problems which may
be aggravated by or interfere with the aforementioned conditions):
If the participant currently suffer from, or has experienced any of the following conditions within the past year,
Please circle the condition below:
Arthritis, Asthma (serious case), Epilepsy, Emotional problems requiring medication, Fainting spells,
Ulcers medication, Rheumatic fever, Major bone or joint injuries, High blood pressure, Major operation or serious illness, Heart trouble, Diabetes, Hypoglycemia, Other medical conditions which might be
aggravated by hiking or strenuous physical activity.
Explain: _________________________________________________________________________
________________________________________________________________________________
Individuals will be allowed to take medications for chronic conditions if the medication is prescribed or
accompanied by a doctor’s approval.
General Appraisal:
____ APPROVAL: I find no medical problems or conditions which I consider incompatible with this program.
_____LIMITED APPROVAL: This individual may participate subject to the limitations listed below.
_________________________________________________________________________________
_____DISAPPROVAL: This individual has medical problems which, in my opinion, clearly constitute
unacceptable hazards to his/her health and safety in this program.
Recommendations and/or restrictions: (if none, specify)
Date: ______________ Signature:_________________________________________________
Doctor’s Name (print): ______________________________________________ Phone:______________
Address: _____________________________________________________________________________
To print, click on bold title above that says, "Permission Slips" and then click green print button.
