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Derby Kansas Stake 2014 Youth Pioneer Trek

**REGISTRATION - PERMISSION - MEDICAL AND PHYSICIAN FORM **
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This form must be completed, signed, and returned to Stake or Ward leaders by Date March 15, 2014. Each participant (adult and youth) must complete a form.

Name (PRINT) ______________________________________M/F ______ Age ______

Birth date (mm/dd/year) ____________ Ward_______________Derby Kansas Stake, KS

Address ___________________________________________________________

Parents' Name (if minor) ______________________________________________

Phone: Home ____________________________ Work ______________________

Other contact person in case of emergency__________Phone_________________

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CONTRACT and RELEASE

● I understand this Pioneer Trek 2014 will be held in a primitive wilderness setting, MAY 29, 30, 31. I also understand although we will be "roughing it", so to speak, that the Stake will provide food, restroom facilities, and safe drinking water.

● 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 Derby Kansas Stake and its staff and Ward leaders from any and all claims for liability arising from my participation in the Pioneer Trek 2014.

● 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 limiting my liquids to water and Gatorade only. I agree to limiting my food items to those provided by the Stake (unless a verified medical condition dictates otherwise). I agree to accepting 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, ipod, blackberries, computers, gameboys, etc. Note: Stake Leaders cell phone numbers are located in the last page of your Trek Handbook – youth will be instructed to ask a Stake Leader to use a phone if it’s an emergency only and visa versa for parents.

● 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

This Pioneer Trek Youth Conference will be held in a wilderness setting. We will be “roughing it”, so to speak. The Stake will provide food, restroom facilities, safe drinking water, 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 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. These considerations should include a warm sleeping bag, warm clothing, a poncho or rain coat, sunscreen, insect repellent, 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. 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.

The Trek will be conducted on private church-owned property, however, 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.

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PARTICIPANT AGREEMENT

I have read and understand the Contract and Release, and agree to act in accordance with the Statement of Responsibility.

Date___________
Signature of Youth________________________________________________

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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 and understand the Contract and Release and the Statement of Responsibility thoroughly and have supplied the above information, which is complete and correct.

This permission includes travel to and from the conference on Commercial Buses, as well as participation at the conference.

I hereby give my full permission for him/her to participate in this youth conference

Date___________ Signature of Parent/Guardian_______________________________

……………………………………………………………………...

Parent/Guardian Sign-Off: Must be completed for all participants:

I grant permission for the Trek participant named above to be photographed, filmed, or videotaped by or for the 2014 Derby Kansas Stake Pioneer Trek. Photos will not be posted to social media, but will be used for a private Trek Blog and/or post trek fireside presentation.

Date___________
Signature of Parent/Guardian_________________________________________

_____________________________________________________________

Derby Kansas Stake 2014 Youth Pioneer Trek

MEDICAL FORM

This form must be completed, signed, and returned to Stake or Ward leaders by Date March 15. Each participant (adult and youth) must complete a form.

To be completed by the parent (or youth 18 yrs old):

Name ________________________ M/F _____ Age ______Birth date _________

Parents' Name (if minor) _____________________________________________

Phone: Home ____________________________ Work ____________________

Health History of Participant

Height _______________ Weight _____________ Family Doctor ________________________

Insurance Company __________________________Policy # ______________________

Medical History

If you currently suffer from, or have experienced any of the following conditions within the past year, please make a check mark next to the condition:

□ 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.

Explain:_________________________________

If you marked any of the above items, you must fill out a Medical Release Form and have it completed and signed by a medical doctor. You cannot participate without it.

Describe any allergies or medication reactions: ________________________________

________________________________________________________________________

Date (approx.) of last Tetanus shot ________________________

Medications currently being used and why: ____________________________________

Have you had more than a minor illness or injury during the past year?

Yes No

If yes, please explain: ______________________________________________________

________________________________________________________________________

Family Physician: __________________________________Phone__________________

Any health concerns we should be aware of?
________________________________________________________________________

________________________________________________________________________

● I agree to the above terms and declare the above statements are complete and correct.
● I agree 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 that 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.

____________________ _______________________________

(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 for themselves)

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Trek 2014 Physician Medical Release Form

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 Medical form. They will not be allowed to participate if this form is not submitted. The examination must be current within 12 weeks of the participation date.

Participant Date of Youth Conference Trek – May 29, 30, 31

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 three days. They will have ample food, water and Gatorade. On the first day they will hike approximately 6 to 7 miles on varying terrain. On subsequent days they will hike approximately 5 miles on varying terrain and engage in other outdoor activities. 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 the Pioneer Trek, individuals suffering from aggravating medical conditions are not to be allowed to participate in some of the regular first day’s activities. However, these individuals may still participate, with your approval, 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 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 in this program.

Recommendations and/or restrictions: (if none, specify)

Date ______________ Signature _________________________________________

Doctor’s Name (print)_______________________________Phone _____________

Address_____________________________________________________________

Derby Kansas Stake 2014 Trek - "Journey of Faith"

Registration-Permission-Medical and Physician Forms