Ward:________________________
Age of youth as of June 10, 2015:________________________
Grade in school that youth is entering as of June 10, 2015:________________________ Gender:________________________
OGDEN UTAH WEBER STAKE 2015 TREK PARENTAL PERMISSION AND MEDICAL RELEASE
This form must be completed, signed in both places, and delivered to your ward YM or YW President by March 15, 2015. Each participant (adult and Youth), must complete a form.
Name:______________________________________________________________ Gender:__________ Date of Birth:____________________
Address:__________________________________________________________
Home Phone:_______________________________________
Parent (if minor):_____________________________________________________
Cell Phone:_________________________________________
Parent (if minor):____________________________________________________
Cell Phone:_________________________________________
Please identify your family physician, medical insurance carrier, and any other information that may be important for insurance purposes if it becomes necessary to obtain medical care for your child.
Family Physician:____________________________________________________________ Phone:_____________________________________
Insurance Company:_________________________________________________________
Policy Number:______________________________
Other:___________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Statement of Responsibility
This Pioneer Trek Youth Conference will be held in a wilderness setting. Participants will be “roughing it.” The Stake will provide food, restroom facilities, safe drinking water, and learning activities. Each participant must act 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 repellant, and other items listed on the personal equipment list. In addition, all participants must proactively ensure that they stay hydrated throughout the activity. 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 4 miles on level ground in 60 minutes or less without undue stress.
The Trek will be conducted on private property. Each participant must abide by the “No Trace Camping” protocols to maintain the wilderness nature of the property. In particular, each participant must avoid littering of any kind.
Name:____________________________________________________ Gender:________________ DOB:____________________________
Health History
If you currently suffer from or if you have ever experienced any of the following conditions please mark the appropriate space below:
⃝ Arthritis ⃝ High blood pressure
⃝ Asthma ⃝ Major operation or serious illness
⃝ Epilepsy ⃝ Heart trouble/Chest Pain
⃝ Emotional problems requiring medication ⃝ Diabetes
⃝ Fainting spells ⃝ Hypoglycemia
⃝ Rheumatic fever
⃝ Other medical or physical conditions which might be
aggravated by this Trek
⃝Other,
please specify:____________________________________________________________________________________
____________________________________________________________________________________________________________
If you marked or completed any of the above items, you may be requested to provide further information, and you may be requested to provide a Medical Release Form completed by a medical doctor.
Describe any allergies or medication reactions:______________________________________________________________________
____________________________________________________________________________________________________________
Medications currently being used:_________________________________________________________________________________
____________________________________________________________________________________________________________
Describe any special diet requirements:____________________________________________________________________________
____________________________________________________________________________________________________________
Have you had any surgeries or major illnesses or injuries?
⃝ Yes ⃝ No If yes, please explain:____________________________________________________________________________
____________________________________________________________________________________________________________
I agree to the above terms and represent that the information provided above is accurate, complete and correct.
Date:________________________
Signature of Participant:_________________________________________________
Parental Permission for Youth Participation and Authorization to Provide Medical Care
I have completed and read the above information pertaining to my child. I am aware that my child will be participating in Trek 2015. I give my permission for my child to participate in this activity and authorize the adults supervising this activity to administer emergency treatment to the above-named participant for any accident or illness and to act in my stead in approving necessary medical care. This authorization shall cover this activity, all preparatory activities, and any travel to and from these activities.
Date:______________________________
Signature of Parent or Guardian:______________________________________________
***CLICK HERE*** to download/print the Form.
