Print Registration - Holladay South Stake Trek

D&C 4:2:
Therefore, O ye that embark in the service of God, see you SERVE him
with all your heart, might, mind and STRENGTH, that ye may STAND
blameless before God the last day.
2015 YOUTH PIONEER TREK
JUNE 30 – JULY 3, 2015
www.hsstrek.com
_________________________________
REGISTRATION
TREK 2015
Our TREK theme this year is “SERVE, SRENGTH, STAND.” Our pioneer ancestors had an
unconquerable belief in Jesus Christ and in the restoration of His gospel. Because of this faith, they
endured unimaginable hardship as they sought a place to worship free from persecution.
As we listen to the warnings of our church leaders today, we know that difficult times are ahead. By
joining in the Trek experience, our youth will:
• Be exposed to the spirit.
• See their ancestors in their shadows as they pull their handcart.
• Learn that they can do hard things.
• Will realize that they too are pioneers in this generation.
We invite all eligible young men and young women in our stake to join us for Trek. Come and learn
what it means to be a pioneer in these latter days. We encourage our graduating seniors to join us
again, even if you participated in Trek four years ago. We need your strength & example.
This is a once in a lifetime, never to be forgotten experience...please don’t miss it!
REGISTRATION COMMITTEE:
Steve Johnson!!
801–652–1117
Stake
Contacts: steveutahsold@gmail.com
Kris Swenson! !
801–712–1718
kswenson801@gmail.com
4th
Ward:
Ann Marie Hopkins! 949–533–4928
annmarie.hopkins@blastsoccer.net
801–455–4265
25th Vicki Smoot! !
Ward: bvsmoot@aol.com
8th
Ward:
Eden Ellinson! !
801–557–5990
dmedmd@msn.com
27th Jill Hodgson! !
Ward: jillynh@gmail.com
14th
Ward:
Janet Sorensen!
801–597–1479
janet.sorensen@gmail.com
801–520–4109
28th Jacelyn Clayton!
jacekkap@gmail.com
Ward:
18th
Ward:
Bekah Pferdner!
801–915–0577
bekahpferdner@gmail.com
801–680–8179
IMPORTANT INFORMATION:
All youth in our Stake who turn 14 years old by September 1, 2015 are invited to participate in Trek
this year. Please call Steve Johnson, Stake Young Men's President & Trail Boss for any questions or
concerns about participating.
Please fill out your forms and return them to your ward registration person as soon as possible. The
deadline for turning in your forms is February 15, 2015.
Emergency contact person: While on Trek ONLY: Larry Pinnock
Home Phone: 801-272-8170 | Cell Phone: 801-558-4017 | Email: lwpinnock@gmail.com or
larry@wcra.cc
REGISTRATION FORM ( PART “A” )
June 30 – July 3, 2015
June 30 – July 3,
HOLLADAY SOUTH STAKE,
WARD
This form must be completed, signed in both places and returned to ward leaders by F e b r u a r y 1 5 , 2015.
Each participant (adult and youth) must complete and submit a form.
NAME: ________________________________________________AGE: ______ BIRTHDAY: ________________
ADDRESS: ____________________________________________________________________________________
SEX: ___________________HEIGHT: ________________________ WEIGHT: ____________________________
PARTICIPANT PHONE #: _____________________ EMAIL ADRESS: __________________________________
HEALTH INSURANCE: _______________________________________ POLICY #: ________________________
PARENT NAME: ______________________________________ PARENT CELL: __________________________
PARENT EMAIL: _______________________________________________________________________________
PARENT NAME: _______________________________________PARENT CELL: __________________________
PARENT EMAIL: _______________________________________________________________________________
EMERGENCY CONTACT (OTHER THAN PARENT): ________________________________________________
RELATIONSHIP TO PARTICIPANT: ______________________ CONTACT’S PHONE #: ___________________
Contract:
I understand this Pioneer Youth Trek will be held in a primitive wilderness setting. I also understand, although we
will be “roughing it”, so to speak, the Stake will provide food, restroom facilities and safe drinking water.
I am a participant in this Trek of my own volition 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 Youth Trek which are beyond
the control of the Stake staff and officers, and I agree to personally assume such risks. Also, the Stake staff
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 absolve the
Holladay South Stake and its staff and officers from any and all claims for liability arising from participation in the
Stake Youth Pioneer Trek. I (and/or my guardian) agree to accept full responsibility for any medical or related bills and
costs incurred which are not covered by Stake DMBA insurance or my own policy.
I grant the Holladay South Stake, the right to take photographs of me and my family in connection with the 2015
Pioneer Trek that I have willingly agreed to participate in. I authorize the Holladay South Stake and its agents to use
and publish the same in print and/or electronically.
I agree to abide by LDS standards. This means maintaining the highest standards of honor and integrity and that
complete abstinence from alcohol, tobacco and harmful drugs are required of every participant involved in this Youth
Trek.
REGISTRATION FORM ( PART “B” )
If you currently suffer from, or have experienced any of the following conditions within the past year, please mark
the appropriate space below:
[
[
[
[
[
[
] obesity
] emotional problems requiring medications
] major surgery or serious illnesses
] high blood pressure
] hypoglycemia
] asthma (serious cases)
[
[
[
[
[
[
] epilepsy
[ ] fainting spells
] arthritis
[ ] ulcers or acid reflux
] rheumatic fever
[ ] diabetes
] heart trouble
[ ] pregnancy
] kidney problems [ ] major bone or joint injuries
] Other medical conditions which might be aggravated by hiking
Explain:
If you marked any of the above items, you must fill out and attach the
completed by a medical doctor; you cannot participate without it!
Medical Release Form , and have it
Allergies to food or medications:
Current medications:
Have you had more than a minor illness in the past 12 months? [ ] Yes [ ] No
If yes, please explain:
Personal Doctor:
Phone:
I AGREE TO THE TERMS OF THIS CONTRACT AND DECLARE THE
ABOVE STATEMENTS TO BE COMPLETE AND CORRECT.
DATE:
SIGNATURE:
I, the undersigned, am aware that my child will be participating in the above designated Stake Youth Pioneer Trek. I
have read the contract and completed the 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 physicians in charge of my child to administer such medical or surgical
treatment or carry out such procedures as may be deemed necessary or advisable in the diagnosis or treatment of my
child.
I agree to the terms of the contract and declare the above statements to be complete and correct.
DATE:
SIGNATURE OF PARENT/GUARDIAN:
(Parent or guardian must sign here if participant is under 18 years of age. 18 and over must sign for themselves)
MEDICAL RELEASE FORM
(PART “C” IF NESSECARY)
This form must be completed and signed by a medical doctor for participants who answered “yes” to any of the
medical conditions listed on the health history section of the registration form. They will not be allowed to participate if
this form is not completed and submitted. The examination must be current within six weeks of the participation date.
PARTICIPANT:
TREK DATES:
Dear Doctor: The above named person will be participating in the Stake Pioneer Trek. Persons suffering from
any of the following conditions must obtain a physician’s clearance before participating in this program. The
participants will be in a wilderness setting for four days. They will have ample food and water. They will be
involved in a strenuous hike on varying terrain. Please consider the following conditions in your evaluation and
assessment:
Obesity
Asthma (serious cases)
Epilepsy
Emotional problems requiring medications
Arthritis
Fainting spells
Ulcers or acid reflux
Major surgery or serious illnesses
Rheumatic Fever
Diabetes
Hypertension
Major bone/joint problems
Cardiac disease
Pregnancy
Hypoglycemia
Life-threatening allergies
Renal problems
Other medical problems which, in your opinion, might be aggravated by the aforementioned circumstances.
Due to the strenuous physical nature of the Stake Pioneer Trek, individuals suffering from diabetes,
hypoglycemia, serious obesity, hypertension or pregnancy, will not be allowed to participate in some of the strenuous
activities. However, these individuals still need your approval to participate in an outdoor experience 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:
[ ] APPROVED - I find no medical problems which I consider incompatible with this program.
[ ] DISAPPROVED- 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, please so specify)
DOCTOR’S NAME (PRINT):
PHONE:
SIGNATURE:
ADDRESS: