Pam Harp
4010 Stone Lakes Dr.
Louisville, KY 40299
In our electronic world I know we would like to do everything electronically. This is one instance where we need physical forms to accompany the youth.Thanks for your understanding and prompt attention.
Louisville KY Stake Pioneer
Trek 2013
July 18-20, 2013
Registration and Medical Form
This
form (front and back) must be completed, signed in both places, and returned by
March 24, 2013 to Ward/Branch
YM or YW leaders. Each trek participant
(adult and youth) must complete a form.
Ward/Branch:
Name: Age: Birth Date:
Address:
Home phone: Cell phone:
Email Address:
Name
of Trek participant you want in your same trek family: ___________________________________
Medical Insurance Co.: Policy #:
Parent’s Name (if minor): Work/Cell Phone:
Parent’s Name (if minor): Work/Cell Phone:
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
pre-authorization phone numbers, name and SSN 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 emergency.
Additional Information:
Statement of
Responsibility
This
Pioneer Trek Youth Conference will be held in a wilderness setting. We will be “roughing it.” The Stake will provide food, restroom
facilities at the campsites, a safe drinking water supply, and learning
activities. 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 Pioneer Trek Youth
Conference, which are beyond the control of the Trek staff and Stake
leaders. Proper preparation reduces
these risks and is the responsibility of all participants. These considerations should include proper
sleeping equipment, poncho or rain coat, sunscreen, insect repellant and other
items listed on the personal equipment list.
All participants must act in such a way as to not endanger themselves or
others, and should show charitable consideration to all other participants and
leaders in the Trek.
Each
participant should condition themselves physically for this experience. An example of adequate conditioning would be
to complete a minimum requirement of walking/running four (4) miles on level
ground in 60 minutes or less without undue stress.
The
trek will be conducted in Bradfordsville on both member’s and non-member’s land. Each participant must follow applicable “No
Trace Camping” protocols to maintain the wilderness nature of the
property. There will be no littering of
any kind while on the trail. Trash
disposal will be available at the campsites each evening.
Individual 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 and provide pertinent details.
Arthritis
|
High
Blood Pressure
|
||
Asthma
(serious case)
|
Major
Operation or Serious Illness
|
||
Epilepsy
|
Heart
Trouble
|
||
Emotional
problems requiring medication
|
Diabetes
|
||
Fainting
Spells
|
Hypoglycemia
|
||
Ulcers
|
|||
Rheumatic
Fever
|
Other
Medical conditions which might be
|
||
Major
Bone or Joint Injuries
|
aggravated
by hiking
|
Explanation:
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 YM or YW leaders.
Allergies,
Special Diets, Reactions to medications:
Medications
currently being used:
Are
immunizations up to date (especially tetanus)?:
Physical
conditions that limit activity:
Have
you had more than a minor illness or injury during the past year, or a
chronic/recurring illness?:
Family
Doctor: Phone:
Participant
Agreement
I
declare that the above statements are complete and correct, 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 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.
Date:
Signature of Parent:
Bishop’s Approval
Date:
Signature of Bishop:
Trek 2013 Medical Release Form
This form must be completed and singed 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 three months of the participation event (July 18-20,
2013).
Participant’s Name:
Dear Doctor: The
above named person will participate in a Pioneer Youth Conference this
summer. 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 three days (emergency access
only during daytime). They will have
ample food and water. On the first day
they will pull a handcart approximately 6-8 miles on varying terrain; the second
day a handcart pull for approximately 5 miles on varying terrain. On day three they will engage in non-exerting
outdoor activities. Participants will
prepare most meals and camp out at night.
Please consider the following conditions in your decision as well as
other medical problems that may be aggravated by or interfere with the below
mentioned conditions:
Arthritis Epilepsy
Emotional problems requiring medication Fainting Spells
Major bone or joint injuries Ulcers
Major operation or serious illness Rheumatic Fever
Diabetes High
Blood Pressure
Heart Trouble Hypoglycemia
Asthma Other
medical condition which might be
aggravated by exertion during outdoor
activities
Due to the strenuous physical nature of the Pioneer Trek
Youth Conference, individuals suffering from aggravating medical conditions may
not to be allowed to participate in some of the regular first or second days’
activities. These individuals need your
approval and recommendations to participate in some or all of the outdoor
activities, handcart pull 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 doctor’s
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 if participating in this
program.
Recommendations and/or
Restrictions: (if none, specify)
Date: Signature:
Doctor’s Name (print): Phone:
Address:
