File

Name:___________________________
Ward:__________________
Trek 2015
June 24-27, 2015
South Jordan Utah Highland Stake
Registration Form & Medical Release
……………………………………………………………………………………………………
This form (2 pages) must be completed, signed, and returned to your ward coordinator
by ______________________. Each participant (adult and youth) must complete a
form. Ward leaders must turn forms in to the Stake by
__________________________.
Name:______________________ Sex:____ Age: _____ Birth Date:_____________
Address: ________________________________________ Phone:_______________
Height: _______________
Weight:___________________
Insurance Company:______________________ Policy #:______________________
Parents’ Name (if minor):______________________ Work Phone:_______________
Parents’ Name (if minor):______________________ Work Phone:_______________
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Contact and Release
1. I understand this Pioneer Trek 2015 will be held in a primitive wilderness setting. I also
understand although we will be “roughing it”, so to speak, that the Stake will provide food,
restroom facilities, and safe drinking water.
2. I am voluntarily a participant in the 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 the Stake
sponsored Trek which are beyond the control of the Stake staff and leaders, and I agree to
personally assume such risks. Also, the Stake staff and 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 Highland South Jordan Stake and its staff and leaders from any and all claims
for the liability arising from my participation in the Pioneer trek 2015.
3. 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. 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.
4. Proper preparation reduces risk and is the responsibility of all participants.
These
considerations should include a warm sleeping bag, warm clothing, a poncho or rain coat,
sunscreen, insect repellent, and other items listed on the personal equipment list. Each
participant, as well, should condition themselves physically for this experience It is
suggested that each participant should be able to complete a minimum requirement of
walking three (3) miles on level ground in 60 minutes or less without undue stress.
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I ___________________________________________ (and/or my guardian) 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.
__________________________________________
Signature of Participant
_____________________
Date
I give permission for my youth to participate in Trek 2015 and authorize the adult leaders
supervising this activity to administer emergency treatment to the above-named participant for
any accident or illness and to act in my stead in approving necessary medical care. This
authorization shall cover this activity and travel to and from the activity.
__________________________________________
Signature of Participants’ Guardian (if minor)
_____________________
Date
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Permission to Use Photographs
I hereby grant Corporation of the President of The Church of Jesus Christ of Latter-day Saints and its
affiliated entities (collectively, “COP”) a royalty-free, worldwide, unlimited, nonexclusive, nonterminable,
perpetual license and permission to freely use my Photographs, taken on Trek, including the right to
reproduce, distribute, rent, lend, perform, display, broadcast, communicate to the public, alter, crop, edit,
modify, adapt, prepare derivative works, and otherwise use the Photographs, either in whole or in part, in
any and all media, in unlimited number, and by any and all means now known or hereafter devised,
together with the right to freely sublicense others to do any or all of the foregoing. To the full extent
permitted by law, I hereby waive, forever and throughout the universe, any and all so-called “moral rights”
now or hereafter recognized with respect to the Photographs and to each and every part thereof for any
and all now known or hereafter existing uses, media, and/or forms. In this regard, I acknowledge and
agree that I will not receive a credit on or in connection with COP’s use of the Photographs. I warrant and
represent that I have read this Permission to Use Photographs and that by signing below I have granted
the permission set forth herein.
__________________________________________
Signature of Participant
__________________________________________
Signature of Participants’ Guardian (if minor)
_____________________
Date
_____________________
Date