Registration And Medical Release Form

 

June   2 9   –   J uly   1 ,   2 017  

Registration   a nd   M edical   R elease   F orm  

 

This   f orm   m ust   b e   c ompleted,   s igned,   a nd   r eturned   t o   y our   w ard   y outh   l eaders   b y   F ebruary   5 ,   2 017.   E ach   p articipant   ( adult  

and   y outh)   m ust   c omplete   a   r egistration     f orm.  

 

Name

Sex

Age

Birth   D ate

Ward

Address

Height

Weight

Insurance   Company

Policy/Group   #

Parents'   N ame  (if  minor)

Parent   C ontact   Information:  

Home   P hone

Mobile   P hone

Work  Phone

CONTRACT   a nd   R ELEASE  

1.

I   u nderstand   t his   P ioneer   T rek   w ill   b e   h eld   i n   a   p rimitive   w ilderness   s etting.   I   u nderstand   t hat,   a lthough   w e   w ill   b e   " roughing   i t,"  

the   S take   w ill   p rovide   f ood,   p ortable   t oilets,   s afe   d rinking   w ater,   a nd   e mergency   m edical   c are.  

 

2.

I   a m   v oluntarily   a   p articipant   i n   t his   P ioneer   T rek   a nd   I   w ill   a ccept   f ull   r esponsibility   f or   m y   a ctions   u nder   a ll   c onditions   a nd  

circumstances.   I   a lso   a gree   t o   a id   o ther   m embers   o f   t he   g roup   i n   b ehaving   r esponsibly.  

 

3.

I   u nderstand   a nd   a ppreciate   t hat   t here   a re   i nherent   r isks   i nvolved   i n   t his   S take-­‐sponsored   P ioneer   T rek   w hich   a re   b eyond   t he  

control   o f   t he   S take   l eaders,   W ard   l eaders,   a nd   l and   o wners,   a nd   I   a gree   t o   p ersonally   a ssume   s uch   r isks.   I n   c onsideration   o f   m y  

participation   i n   t his   P ioneer   T rek,   a nd   f or   o ther   g ood   a nd   v aluable   c onsideration,   t he   r eceipt   a nd   s ufficiency   o f   w hich   a re  

acknowledged,   I ,   i ntending   t o   b ind   m yself   a nd   m y   h eirs,   p ersonal   r epresentatives,   s uccessors,   a nd   a ssigns,   d o   h ereby   e xpressly  

release   a nd   f orever   d ischarge   t he   W ashington   T errace   U tah   E ast   S take   a nd   i ts   l eaders,   t he   W ard   l eaders   a nd   t he   l and   o wners,   t o  

the   e xtent   a nd   o nly   t o   t he   e xtent   n ot   c overed   b y   i nsurance,   f rom   a ny   a nd   a ll   c laims,   d emands,   c auses   o f   a ction,   a nd   o ther   r ights   o f  

any   n ature   w hatsoever   t hat   I   m ay   h ave   t hat   a rise,   d irectly   o r   i ndirectly,   f rom   o r   b y   r eason   o f   a ny   b odily   o r   p ersonal   i njuries   a nd/or  

death   o r   p roperty   d amage   r esulting   i n   a ny   w ay   f rom   m y   p articipation   i n   t his   P ioneer   T rek,   w hether   c aused,   d irectly   o r   i ndirectly,   b y  

any   a ct   o r   o mission   o f   a ny   S take   o r   W ard   l eader   o r   o therwise.   It   i s   n ot   t he   i ntent   o f   t his   p rovision   t o   r elease   i n   a ny   w ay   c laims   t hat  

are   c overed   b y   i nsurance.   I   a lso   h ereby   e xpressly   a gree   t o   i ndemnify   a nd   h old   h armless   t he   W ashington   T errace   U tah   E ast   S take  

and   i ts   l eaders,   t he   W ard   l eaders   a nd   t he   l and   o wners,   t o   t he   e xtent   n ot   c overed   b y   i nsurance   e ither   s pecially   p urchased   f or   t his  

event   o r   o therwise   e xisting,   f rom   a nd   a gainst   a ny   a nd   a ll   l osses,   d amages   a nd   c osts   ( including   r easonable   a ttorneys’   f ees)  

arising   f rom   o r   r elating   t o   a ny   c laims,   d emands,   a ctions   o r   j udgments   o f   a ny   c haracter   w hatsoever   t hat   m ay   b e   b rought   o r  

obtained   b y   m y   o r   m y   h eirs,   f amily   o r   r elatives,   r esulting   d irectly   o r   i ndirectly   i n   a ny   w ay   f rom   m y   p articipation   i n   t his   P ioneer  

Trek.  

 

4.

I   a gree   t o   a bide   b y   L DS   s tandards.   T his   m eans   h igh   s tandards   o f   b ehavior,   h onor   a nd   i ntegrity,   a bstinence   f rom   a lcohol,   t obacco  

and   a ny   h armful   d rugs/substances.  

 

5.

I   a gree   t o   l imit   m y   p ersonal   p ossessions   d uring   t his   P ioneer   T rek   t o   o nly   t hose   i tems   o n   t he   o fficial   a pproved   l ist.  

 

6.

I   ( and/or   m y   g uardian)   a gree   t o   a ccept   f ull   r esponsibility   f or   a ny   m edical   o r   r elated   e xpenses   i ncurred   w hich   a re   n ot   c overed   b y  

my   o wn   i nsurance   p olicy.   M edical   a nd   d ental   b enefits   f rom   t he   C hurch   A ctivity   I nsurance   P rogram   m ay   b e   a vailable,   b ut   t hey   a re  

secondary   t o   o ther   i nsurance   c overage   a nd   s ubject   t o   l imitations.   C ontact   y our   b ishop   o r   b ranch   p resident   f or   p lan   c overage   o r   a  

benefit   c laim   f orm   i n   c ase   o f   a n   a ccident.  

 

7.

I   a gree   t hat   a s   a   p articipant   i n   t his   P ioneer   T rek,   i t   i s   m y   r esponsibility   t o   c ondition   m yself   p hysically   f or   t his   e xperience.   I  

understand   t hat   i t   w ill   b e   h eld   i n   m ountainous   t errain   a nd   w ith   l imited   f acilities.   I   c an   w alk   a t   l east   4   m iles   o n   r olling   g round   i n   6 0  

minutes   o r   l ess   w ithout   u ndue   p hysical   s tress.  

 

8.

I   a gree   t o   f ollowing   t he   “ no-­‐trace   c amping”   p rotocols   i n   o rder   t o   m aintain   t he   w ilderness   n ature   o f   t he   p roperty.