Grove Creek Stake Pioneer Trek 2012

Youth Name: ____________________________ Phone #:______________Age: ______________ Sex: M / F Height: ______________ Ward:________________ Birthday:______________ Weight: _______________

1. I understand that I will push or pull a heavily loaded handcart up to 14 miles in one day. 2. I am a participant in this trek of my own volition, and I will accept full responsibility of my action s under all conditions. I also agree to aid other members of the group in behaving responsibly and promoting an overall positive attitude within my assigned trek family. 3. I agree to abide by the LDS "For the Strength of Youth" booklet standards. This means that high standards of honor, integrity, and abstinence for alcohol, tobacco, and harmful drugs are required of every participant during the trek. If misbehavior occurs, I understand that my parents will be called to come and take me home. 4. I will condition myself physically for this experience to the point that I am able to complete the minimum requirement of walking/running four miles on level ground in 40 minutes without undue stress. (This is not to exclude anyone with physical disabilities.) 5. In order to make this as authentic as possible, I agree to conform to the required dress code. We have read this contract and we both understand and agree to these conditions. Youth Signature: _______________________________________________________________ Parent/Guardian Signature:_______________________________________________________ (Deadline: Completed registration form needed by Sunday, May 20th.)

Grove Creek Stake Pioneer Trek 2012 – Medical Form

Youth Name: ____________________________

Ward:________________

Emergency Contact Information Name: ____________________________ Address: ____________________________ ____________________________ Doctor Name: ____________________________ Home Phone #:______________ Work Phone #:______________ Cell Phone #:______________ Phone #:______________

Insurance Carrier/Policy #:________________________________________________________ Do you have any of the following? Yes Yes Yes Yes Yes Yes No No No No No No Special Diet / Food Requirements Allergies (including food allergies) Chronic or recurring illness Physical conditions that would limit you from any activity Medications (to be taken while on the trek) Any medical condition that would be aggravated by prolonged exposure to the sun

If you answered yes to any of the above, please explain (be specific and detailed; use back if needed):

I agree to accept full responsibility for any medical or related bills incurred that are not covered by Stake DMBA insurance or my own insurance policy. Parent/Guardian Signature: ________________________________________________________