Silverdale Stake PIONEER TREK - ADULT REGISTRATION FORM

Trek Dates: 6/25/2014 - 6/28/2014 Location: Bing Canyon Pioneer Camp

This form (2 pages) must be completed, signed in both places, and returned to your ward YM/YW president by November 3, 2013. Each participant must complete a form.

Name:______Gender:____ Age:____ D.O.B.:______Height: ______Weight: ______Address:______Phone:______Cell:______E-mail:______Insurance Company:______Policy #:______Additional contact name:______Phone:______

CONTRACT and RELEASE

 I understand Pioneer Trek 2014 will be held at the LDS Church owned property, Bing Canyon Pioneer Camp, in Plymouth, Washington. I also understand that although we will be “roughing it”, the Stake will provide ample food, safe drinking water, and ample restroom facilities.  I am voluntarily a participant in this Trek and I will accept full responsibility for my actions under all conditions. I also agree to encourage other members of the group to behave responsibly.  I understand and appreciate that there are inherent risks involved in this Stake-sponsored Trek, which may be beyond the control of the stake Trek staff and/or ward leaders, and I agree to personally assume such risks. I understand stake Trek staff and/or ward leaders cannot be held responsible for any injuries. Furthermore, I am responsible for all expenses, costs and/or claims in connection with injuries sustained not directly caused by a leader's failure to take due care. I hereby also agree to release, hold harmless and indemnify the Silverdale, Washington Stake of the Church of Jesus Christ of Latter-day Saints and its members, leaders and Trek Staff from and against any and all claims for liability/damages arising from my participation in the Pioneer Trek 2014.  I agree to accept full responsibility for any medical or related expenses 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 for plan coverage or a benefit claim form in case of an accident.)  I agree to abide by LDS standards as outlined in the For the Strength of Youth Pamphlet. This means high standards of behavior, honor and integrity. I will abstain from alcohol, tobacco and harmful drugs during Trek. HEALTH HISTORY

Are all immunizations current? (Yes / No) If not, explain:______Date of last Tetanus Booster:______

If you currently suffer from, or have experienced any of the following conditions within the past year, please mark the appropriate space below:

Arthritis High Blood Pressure Asthma (serious case) Major operation or serious illness Epilepsy Heart trouble Emotional problems requiring medications Diabetes Fainting Spells Hypoglycemia Ulcers medication Other medical conditions which might be Rheumatic fever aggravated by hiking Major bone or joint injuries Any known medication allergies

Explain:______

If you marked ANY of the above items, you MUST fill out a yellow Medical Release Form, available from your ward YM/YW President, and have it completed by a medical doctor. You will not be allowed to participate on Trek without it. Please mail the Medical Release Form to Trek Medical Committee Leader: Dr. Richard Thompson, 13700 NW Rocky Ridge Rd., Silverdale, WA 98383.

Describe any allergies or reactions to medications: ______

Medications currently being used:______

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

If yes, please explain:______

Family Doctor:______Phone:______

I agree to the above terms and declare the above statements are complete and correct to the best of my knowledge. ______(Date) (Signature of Participant)

I am aware I will be participating in Pioneer Trek 2014. I have read the Contract and Release and have completed the Health History. In the event that any medical attention is needed, I hereby authorize any adult leaders to seek medical treatment on my behalf from authorized Medical Personnel, including those traveling with Trek Staff. Such Medical Personnel may administer treatment and perform medical procedures, as they deem necessary or advisable. Furthermore, Trek Medical Personnel may seek additional support from emergency medical response teams.

On behalf of myself, I agree to the terms of the Contact and Release and declare the above statements are complete and correct to the best of my knowledge.

______(Date) (Signature of Participant)