Grove Creek Stake Pioneer Trek 2012 Registration Form

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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 be
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   Grove Creek Stake Pioneer Trek 2012 Youth Name: ____________________________ Ward:________________Phone #:______________Age: ______________ Birthday:______________Sex: M / F Height: ______________ 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 sunder all conditions. I also agree to aid other members of the group in behaving responsibly andpromoting 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 highstandards 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 tocome and take me home.4. I will condition myself physically for this experience to the point that I am able to complete theminimum requirement of walking/running four miles on level ground in 40 minutes without unduestress. (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 20 th .)  Are you related to any Latter-Day Saint pioneers who came across the plains by handcart? If so, pleaseinclude their name(s) here:  Grove Creek Stake Pioneer Trek 2012 – Medical Form Youth Name: ____________________________ Ward:________________ Emergency Contact Information Name: ____________________________ Home Phone #:______________Address: ____________________________ Work Phone #:______________ ____________________________ Cell Phone #:______________Doctor Name: ____________________________ Phone #:______________Insurance Carrier/Policy #:________________________________________________________ Do you have any of the following? Yes No Special Diet / Food RequirementsYes No Allergies (including food allergies)Yes No Chronic or recurring illnessYes No Physical conditions that would limit you from any activityYes No Medications (to be taken while on the trek)Yes No Any medical condition that would be aggravated by prolonged exposure to the sunIf 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 StakeDMBA insurance or my own insurance policy.Parent/Guardian Signature: ________________________________________________________
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