Lindon West Stake Youth Pioneer Trek

Trek Date: July 28-30, 2016

Registration/Medical/Parental Permission Form
Who Can Go On The Trek:
We invite all Stake youth, 14 years old by August 31, 2016, and those seniors just graduating from High School
that belong to our stake. Also, adult leaders who have been called and assigned to participate
Everyone (Adults as well as Youth) who will go on the trek MUST complete the registration forms provided
below.
.............................................................................................................
This form (both sides, pages 1-3) must be completed, signed in both places, and returned to your ward
Young Men or Young Womens president by April 20, 2016. Each participant (adult and youth) must complete
a separate form. Ward leaders must return these forms to the Stake by April 24, 2016.
Name ________________________________ Sex ___ Age ___ Birth date ______________ Ward________
Address _____________________________________________________, Lindon Utah.
Height _______________

Weight ______Doctors Name (print)_________________________________

Insurance Company _____________________________________________________________________

Policy # ________________________________
Parents' Name (if minor) ___________________________________________
Phone # _____________________________ Work # _______________________________

....................................................................................................................
PERSONAL COMMITMENT
1.

I understand this Pioneer Trek 2016 will be held in a primitive wilderness setting. I also understand although we will be
"roughing it", 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 Lindon Utah West Stake and its
staff and Ward leaders from any and all claims for liability arising from my participation in the Pioneer Trek 2016.
I agree to abide by LDS standards. 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.
I agree to accept the family I am assigned. I will have a willingness to share chores. I will join in trek family activities. I agree
to leave all electronic devices at home, including but not limited to: cell phones, iPods, iPads, Blackberries or iPhones,
Laptops, Gameboys, or any other electronic device not mentioned.
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.

Statement of Responsibility
Each participant in this conference must act in accordance with church standards at all times, and aid other members of the
conference in behaving in accordance with church standards. There are inherent risks involved in all outdoor activities, including this
Stake sponsored Youth Conference, which are beyond the control of the Stake staff and officers. Proper preparation reduces these
risks and is the responsibility of all participants. A personal equipment list will be provided and all participants should bring the items
required and should not bring those items prohibited.
Note: On the first day we will hike approximately 6 miles on varying terrain. On the second day we will hike approximately
17 miles on varying terrain and engage in other outdoor activities. On the third day we will hike approximately 6 miles. Each
participant should condition themselves physically for this experience. Specifically, each participant should prepare by walking
significant distances in the weeks leading up to this activity as preparation for this activity.
The Trek will be conducted on public property. Each participant must follow applicable No Trace Camping protocols to
maintain the wilderness nature of the property. Especially, each participant must avoid littering of any kind.

Participant Agreement
I have read and agree to act in accordance with the Statement of Responsibility.
Date______________ Signature of Participant _________________________________________________

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
below, 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.
Date_____________ Signature of Parent__________________________________________________

Health 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 medication
Rheumatic fever
Major bone or joint injuries
High blood pressure
2

Major operation or serious illness

Heart trouble
Diabetes
Hypoglycemia
Other medical conditions which might be aggravated by hiking.

Explain: ________________________________________________________________ Use back of page if needed.

If you marked any of the above items, you must fill out a Medical Release Form on page 4 and have it
completed by a medical doctor; you cannot participate without it.
Describe any allergies or medication reactions: ___________________________________________
___________________________________________________________________________________
Describe any food allergies or special dietary requirements, ie. Nuts, gluten, dairy, eggs, etc.:
__________________________________________________________________________________________
Medications currently being used:

_____________________________________________________

Have you had more than a minor illness or injury during the past year?
Yes
No
If yes, please explain: _________________________________________________________________
___________________________________________________________________________________
Family Doctor _______________________________________Phone__________________________
I agree to the above terms and declare the above statements are complete and correct.
_____________________
______________________________________________
(Date)
(Signature of Participant)
As a parent, I am aware that my child will be participating in Pioneer Trek 2016. I have read the
Contract and Release and the completed health history, and I am aware of the circumstances my child will
undergo, and I hereby give my full permission for him/her to participate. Also, in the event any medical
attention is needed, I hereby authorize any leaders to seek medical treatment and medical personnel 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.
I agree to the terms of the Contract and Release and declare the above statements are complete and
correct.
____________________
____________________________________________
(Date)
(Signature of Parent/Guardian)
(Parent or guardian must sign here if participant is under 18 years of age.
Participants 18 or older must sign here--for themselves

Trek 2016 Medical Release Form

(Completed only if checked any of the health history boxes listed above)
This form must be completed and signed by a medical doctor for participants who answered yes to any of 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 weeks of the participation date.
Participant

Date of Conference _July 28-30, 2016________________

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 physicians clearance before participating in this program. The
participants will be in a wilderness setting for three days. They will have ample food and water. On the first day
they will hike approximately 6 miles on varying terrain. On the second day they will hike approximately 17 miles
on varying terrain and engage in other outdoor activities. On the third day they will hike approximately 6 miles.
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):
Arthritis
Emotional problems requiring medication
Major bone or joint injuries
Major operation or serious illness
Diabetes
Pregnancy
Hypoglycemia
Asthma

Epilepsy
Fainting spells
Ulcers
Rheumatic fever
High blood pressure
Heart trouble
Other medical conditions which might be
aggravated by hiking

Due to the strenuous physical nature of Pioneer Trek Youth Conference, individuals suffering from aggravating
medical conditions are not to be allowed to participate in some of the regular activities. However, these
individuals still need your approval to participate in subsequent outdoor activities and hiking where medical
facilities are limited.
Individuals will be allowed to take medications for chronic conditions if the medication is prescribed or
accompanied by a doctors approval.
General Appraisal:
( ) APPROVAL: I find no medical problems 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

Doctors Name (print)______________________________________________Phone
Address)
______________________________________________________________________