Name______________________________ Page 4

MEDICAL INCIDENT REPORT

Date of Incident: ____________ Time of Incident: __________ AM/PM Name: ______________________________________________ age: ______ Address:________________________________________________________________ _________________________________________ Phone: ________________________ Stake Group: ____________________________________________________________ Location of incident: ______________________________________________________ Brief description of the facts of the incident: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Injured body part(s): _________________________________ right/left:_________ Nature of injury (cut, break, scrape, etc.): _____________________________________________________________________ _____________________________________________________________________ Witnesses:____________________________________________________________ Individuals contacted (parents, bishop, stake president, etc.) ________________________________________________________________________ TREATMENT Healthcare provider: ____________________MD DO PA RN LPN Medic EMT Address: ________________________________________________________________ __________________________________________ Phone: _______________________ Treatment given: ________________________________________________________ Medications: ____________________________________________________________ Referred to: _____________________________________________________________ Condition: ______________________________________________________________ Signature of provider: ___________________________________ Time: ________

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

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_____Arthritis _____Emotional problems requiring medication _____Major bone or joint injuries _____Major operation or serious illness _____Diabetes _____Pregnancy _____Hypoglycemia ______ Epilepsy ______ Fainting spells ______ Ulcers ______ Rheumatic fever ______ High blood pressure ______ Heart trouble ______ Other medical conditions which may be aggravated by hiking Explain:______________________________________________________________________ ______________________________________________________________________________ ****If you marked any of the above items, you must fill out the Medical Release Form (page 3) and have it completed by a medical doctor; you cannot participate without it. **** Allergies, special diets, or medication reactions: Medications currently being used: ________________________________________ _________________________________ ________________________________________ _________________________________ ________________________________________ _________________________________ Are immunizations up to date (especially tetanus shot)?___________ Have you had more than a minor illness or injury during the year, or a chronic/recurring illness, hospitalization? If Yes, Please Explain: ______________________________________________________________________________ ______________________________________________________________________________ Family Doctor Name and Phone:___________________________________________________

**Participant Agreement** I declare that the above statements are complete and correct. Date___________Signature of Parent/Participant____________________________ Parental Permission I, the undersigned, am aware that my youth will be participating in the above designated Stake Pioneer Trek. I have read the Statement of Responsibility and have supplied the medical statements above, which are complete and correct. I hereby give my full permission for him/her to participate in this youth conference and authorize the adult leaders supervising this activity to administer emergency treatment for any accident or illness and to act in my stead in approving necessary medical care. In the even 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 procedure as may be deemed necessary or advisable in the diagnosis or treatment of my child. This permission includes travel to and from the trek as well as participation at the trek. ***Date___________ Signature of Parent___________________________________

Physician MEDICAL RELEASE FORM

This form must be completed and signed by a medical doctor for participants who answered yes to any of the conditions listed on the Medical History portion of the Registration form.

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They will not be allowed to participate if this form is not submitted. The examination must be current within 3 months of the participation date. Participant Date of Conference July 25th-28th Dear Doctor: The above named person will participate in a Pioneer Youth Conference. Persons suffering from any of the conditions listed below must obtain a physicians 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 hike approximately 8-9 miles on varying terrain and engage in other outdoor activities. Please consider the following conditions in your decision (as well as other medical problems which may be aggravated by or interfere with the aforementioned conditions): ___Arthritis ___Emotional problems requiring medication ___Major bone or joint injuries ___Major operation or serious illness ___Diabetes ___Pregnancy ___Hypoglycemia ___Asthma ___Epilepsy ___Fainting spells ___Ulcers ___Rheumatic fever ___High blood pressure ___Heart trouble ___Other medical conditions which might be aggravated by hiking Due to the strenuous physical nature of Pioneer Trek Youth Conference, individuals suffering from aggravating medical conditions where they can not tolerate heat, hiking up to nine miles/day and hiking where medical facilities are limited should not to be released to participate in Trek. Individuals will be allowed to take medications for chronic conditions if the medication is prescribed or accompanied by a doctors approval. General Appraisal: ( ) APPROVAL: I find no medical problems which I consider incompatible with this program. ( ) DISAPPROVAL: This individual has medical problems which, in my opinion, clearly constitute unacceptable hazards to his/her health and safety in this program. Date ______________ Signature______________________________________ Doctors Name (print)_____________________________________________

Date: _____________________

REGISTRATION FORM
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Name______________________________ Page 4 This form must be completed, signed, and returned to ward coordinator by June 17, 2012. Each participant (adult and youth) must complete a form. Name ________________________ Sex ___Age ____ Birth date _________________ Address ________________________________________________________ Height _______________ Weight _____________ Insurance Company _________________________________ Policy # _________________ Parents' Name (if minor) __________________________ Phone __________________ Work _________________ ............................................................................................................................................... CONTRACT and RELEASE 1. I understand this Pioneer Trek 2012 will be held in a primitive wilderness setting. I also understand we will be "roughing it", so to speak, that the Stake will provide food, restroom facilities, and safe drinking water. There are inherent risks involved in all outdoor activities, 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. 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 four(4) miles on level ground in 60 minutes or less and eight to nine miles/day without undue stress. The Trek will be conducted on private property. Each participant must follow applicable No Trace Camping protocols to maintain the wilderness nature of the property. Especially, each participant must avoid littering of any kind. 2. I am voluntarily a participant in this Trek 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 Trek which are beyond the control of the Stake staff and Ward leaders, and I agree to personally assume such risks. Also, the Stake staff and Ward leaders 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 release the Syracuse West, Utah Stake and its staff and Ward leaders from any and all claims for liability arising from my participation in the Pioneer Trek 2012. I agree to abide by LDS standards. This means high standards of behavior, honor and integrity; and abstinence from alcohol, tobacco and harmful drugs are required of me and every participant involved in this Trek. I (and/or my guardian) agree to accept full responsibility for any medical/related expense 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 or branch president for plan coverage or a benefit claim form in case of an accident. As a parent, I am aware that my child will be participating in Pioneer Trek 2012.

Name______________________________ Page 4 I have read the Contract and Release and the completed 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 leaders to seek medical treatment and medical personal in charge of my child to administer such medical or surgical treatment or carry out such procedure as may be deemed necessary or advisable in the diagnosis or treatment of my child. I agree to the terms of the Contract and Release and declare the above statements are complete and correct. __________________ (Date) _______________________________ Participant/ (Signature of Parent/Guardian-minors)

(Parent or guardian must sign here if participant is under 18 years of age) Participants 18 or older must sign here--for themselves