Registration And Release Form printable pdf download

Fruit Heights Utah Stake 2016 Pioneer Trek

June 29 – July 2, 2016

Registration and Medical Release Form

This form must be completed, signed, and returned to your ward youth leaders by April 17, 2016 (the date of the Trek Kickoff

Fireside). Each participant (adult and youth) must complete a registration form.

Name ______________________________________ Sex _____ Age _____ Birth Date ________________ Ward__________

Address _______________________________________________________________________________________________

Height _______________ Weight _____________

Insurance Company ________________________________________________________________

Policy/Group # ____________________________________________________________________

Parents' Name (if minor) _____________________________________________________________

Parent Contact Information:

Home Phone _______________________ Mobile Phone ______________________ Work Phone______________________

CONTRACT and RELEASE

I understand this Pioneer Trek will be held in a primitive wilderness setting. I understand that, although we will be "roughing it,"

the Stake will provide food, portable toilets, safe drinking water, and emergency medical care.

I am voluntarily a participant in this Pioneer Trek and I will accept full responsibility for my actions under all conditions and

circumstances. 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 Pioneer Trek which are beyond the

control of the Stake leaders, Ward leaders, and land owners, and I agree to personally assume such risks. In consideration of my

participation in this Pioneer Trek, and for other good and valuable consideration, the receipt and sufficiency of which are

acknowledged, I, intending to bind myself and my heirs, personal representatives, successors, and assigns, do hereby expressly

release and forever discharge the Fruit Heights Utah Stake and its leaders, the Ward leaders and the land owners, to the extent

and only to the extent not covered by insurance, from any and all claims, demands, causes of action, and other rights of any

nature whatsoever that I may have that arise, directly or indirectly, from or by reason of any bodily or personal injuries and/or

death or property damage resulting in any way from my participation in this Pioneer Trek, whether caused, directly or indirectly,

by any act or omission of any Stake or Ward leader or otherwise. It is not the intent of this provision to release in any way claims

that are covered by insurance. I also hereby expressly agree to indemnify and hold harmless the Fruit Heights Utah Stake and its

leaders, the Ward leaders and the land owners, to the extent not covered by insurance either specially purchased for this event

or otherwise existing, from and against any and all losses, damages and costs (including reasonable attorneys’ fees) arising from

or relating to any claims, demands, actions or judgments of any character whatsoever that may be brought or obtained by my or

my heirs, family or relatives, resulting directly or indirectly in any way from my participation in this Pioneer Trek.

I agree to abide by LDS standards. This means high standards of behavior, honor and integrity, abstinence from alcohol, tobacco

and any harmful drugs/substances.

I agree to limit my personal possessions during this Pioneer Trek to only those items on the official approved list.

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 or branch president for plan coverage or a

benefit claim form in case of an accident.

I agree that as a participant in this Pioneer Trek, it is my responsibility to condition myself physically for this experience. I

understand that it will be held in mountainous terrain and with limited facilities. I can walk at least 4 miles on rolling ground in 60

minutes or less without undue physical stress.

I agree to following the “no-trace camping” protocols in order to maintain the wilderness nature of the property.

Registration And Release Form