I, (type name) First Name* Last Name* , the undersigned, as parent/legal guardian, or myself, state the above noted medical and health information is true and correct so far a I know and hereby authorize the Trek health Supervisor, Trek staff, or driver of a transporting vehicle to obtain first aid or other care as seems prudent to above named individual in the event of accident or illness.I understand I will be held responsible for any medications brought to trek by person herein described. I hereby give permission to administer prescribed medication as well as over the counter medication according to as is indicated above.I further authorize said persons to initiate any or all provisions for medical and/or surgical care for above named individual, including anesthesia, which may be deemed necessary or advisable by any licensed First Responder, Emergency Room Personnel, or Physician.I assume and shall be responsible for all medical costs and expenses in connection with the care and control of above named individual, except in so far as there is applicable insurance covering the same.In the event of an incident requiring medical attention, I expect that every effort will be made to notify myself or the below named emergency contacts. Parent/Legal Guardian/18 yr. Old Youth/Adult Staff: (type name) First Name* Last Name* Date* Signature * Emergency Contacts:Name: First Name* Last Name* Phone #1: Area Code* Phone Number*Phone #2: Area Code* Phone Number*Name: First Name* Last Name* Phone #1: Area Code* Phone Number* Phone #2: Area Code* Phone Number*
Participant Statement of Responsibility: The Antelope Stake Youth Handcart Trek will be held in a wilderness setting. We will be "roughing it" so to speak. The Stake will provide food, safe drinking water, and restroom facilities. Each participant in this trek must act in accordance with church standards. There are inherent risks involved in all outdoor activities, including this Stake sponsored trek, which are beyond the control of the Stake staff and officers. Proper preparation reduces the 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 repellent, and other items listed on the personal equipment list. All participants must act in a way as to not endanger themselves or others, and show charitable consideration to all other participants and leaders on 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 without undue stress. Each participant must follow applicable "Leave No Trace" camping protocols to maintain the wilderness nature of the property we will trek on. Especially, each participant must avoid littering of any kind. Participant Agreement:I, declare that the above statements are complete and correct, and agree to act in accordance with the Statement of Responsibility. Signature of Participant: Signature* Date: Date*
Parental Permission:I, the undersigned, am aware that my youth will be participating in the above designated Stake Pioneer Handcart 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 pioneer trek. This permission includes travel to and from the trek as well as participation in the trek. Signature of Parent: Signature* Date: Date*