Attached you will find copies of the Registration/Medical release form. Please print and fill out. All adults and youth will need to have the Registration and Medical form filled out. Also, please mail all completed forms to:

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:

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:

Faith in every Footstep

Monday, January 14, 2013

Registration / Medical release forms