Registration And Release Form (Page 2 of 2) in pdf

Health History and Medical Release

If you currently suffer from, or have experienced any of the following conditions within the past year, please mark the

appropriate space below:

_____ Arthritis

_____ Major bone or joint injury

_____ Asthma (serious case)

_____ High blood pressure

_____ Epilepsy

_____ Any major operation or serious illness

_____ Ulcers

_____ Emotional problems requiring medication

_____ Fainting spells

_____ Rheumatic fever

_____ Heart problems

_____ Diabetes/Hypoglycemia

_____ Any medical conditions which might be aggravated by hiking or participating in the Pioneer Trek

Explain if any of the above are checked: ____________________________________________________________________

_____________________________________________________________________________________________________

(If you marked any of the above items, you may be requested to fill out a 2016 Pioneer Trek Physician Medical Release Form

and have it completed by a medical doctor. If that form is requested, you cannot participate without it.)

Describe any medication allergies/reaction: __________________________________________________________________

______________________________________________________________________________________________________

Medications currently being used: __________________________________________________________________________

______________________________________________________________________________________________________

□

Check any known food allergies:

Dairy

Gluten/Wheat

Peanut

Other – please explain____________________

_____________________________________________________________________________________________________

Family Doctor _______________________________________________ Phone_____________________________

By signing below, the participant or his or her parent or guardian hereby (1) authorizes the Stake and Ward leaders to

use the above medical information in connection with this Pioneer Trek and (2) authorizes the participant’s health care providers

to complete the attached 2016 Pioneer Trek Medical Release Form, if requested, and to release and disclose to the Stake and

Ward leaders all information relating to the participant’s medical conditions as they may relate to participation in this Pioneer

Trek. This authorization shall constitute consent to the release of such information under all current and future laws, rules, and

regulations, including, without limitation, the medical information privacy law and regulations generally referred to as HIPAA.

I agree to the terms of the Contract and Release, and I further agree that the release and indemnification provisions in

paragraph 3 of that Contract and Release apply in full force to me, my heirs, personal representatives, successors, and assigns,

and I declare that the above statements are complete and correct.

I agree to all of the above terms and declare that the above statements are complete and correct.

_____________________

________________________________________________

(Date)

(Signature of Participant)

As a parent, I am aware that my child will be participating in the Fruit Heights Utah Stake 2016 Pioneer Trek. I have read

the foregoing Contract and Release, I have completed the Health History and Medical Release, I am aware of the circumstances

my child will face on the Pioneer Trek, and I hereby give my full permission for him/her to participate. In the event any medical

attention is needed, I hereby authorize Stake and Ward leaders to seek appropriate medical treatment and authorize the medical

personnel in charge of my child to administer such medical care or treatment necessary or advisable in the diagnosis and/or

treatment of my child.

____________________

________________________________________________

(Date)

(Signature of Parent/Guardian)

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

Registration And Release Form Page 2

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