Pioneer Trek Registration Form

Ephrata Stake – June 21-24, 2017

ALL on-site participants/volunteers, whether on or off the trail, must submit this form. (So we know

how many to feed!). Form must be returned to your ward YM/YW adult leaders by Sunday April 30.

Ward leaders must turn forms into Stake Trek leaders Julie and Doug Larsen (julie@willowdrive.com) or

Kyle and Necia Bair (neciabair@gmail.com), by Sunday May 7.

Name: _________________________________ Sex: M / F Age: ______ Birth date: _________

(youth) Ward:_____________

1st Aid/CPR certified: Yes / No

Insurance Company: ________________________________ Policy #: _________________________

Parents’ Name (if minor): _______________________________________________________________

Home Phone: _____________________________ Cells: ______________________________________

Adult Volunteers: special areas of interests in helping: ________________________________________

Days available: Pre-trek Prep, Wednesday, Thursday, Friday, Saturday (please circle when available)

Statement of Responsibility & Commitment

1. I understand this Pioneer Trek 2017 will be held in a primitive wilderness setting, where we will

be “roughing it.” There are inherent risks involved with this activity. Church leaders cannot be

held responsible for expenses or claims in connection with any injuries sustained. 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. The Stake will provide food, restroom facilities,

and safe drinking water.

2. As a voluntary participant in this Trek, I will act in accordance with LDS church standards at all

times, and aid other members of the Trek in doing the same.

Participant’s Signature: ___________________________________ Date: _________________

Parental Permission: I have read the above Statement of Responsibility and Commitment. I will support

the leaders of the trek and will encourage my child to do the same.

Parent/guardian’s signature: _______________________________ Date: ____________________

(for minor participants)

Pioneer Trek – Medical/Health Form

Health History

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

please mark the appropriate space below:

Arthritis

Asthma (serious case)

Epilepsy

Emotional problems requiring

medication

Fainting spells

Ulcers medication

Rheumatic fever

Major bone or joint injuries

High blood pressure

Major operation or serious illness

Heart trouble

Diabetes

Hypoglycemia

Other medical conditions which might

be aggravated by hiking

If you marked any of the above items, please explain in detail your medical condition, and any necessary

accommodations required. Please notify and work with your ward YM/YW leader on this. Come

prepared with medications, emergency info, etc.

Describe any allergies, special diets, or medication reactions: __________________________________

____________________________________________________________________________________

Medications currently being used: ________________________________________________________

_____________________________________________________________________________________

Did you have a serious illness or injury the past year, or a chronic/recurring illness? Yes / No

If yes, please explain: ___________________________________________________________________

_____________________________________________________________________________________

Family doctor: ___________________________________ Phone: _____________________________

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

Participant’s signature: ____________________________ Phone: _____________________________

As a parent/guardian, I am aware that my child will be participating in Ephrata Pioneer Trek 2017. As a

parent I declare that the above health statements are complete and correct. I give my permission for

my child to participate in this trek. In the event any medical attention is needed I hereby authorize adult

leaders to administer emergency treatment for my child, and to approve necessary medical care, until I

can be contacted for further action.

Parent/Guardian’s signature: ____________________________________ Date: __________________

(if participant is a minor) phone #: _________________________ optional phone #: _______________

Start Preparing NOW

Begin gathering clothing and supplies . . .

You will need 1 5-gallon bucket with lid (a screw top lid is recommended)

1 Sleeping bag

1 Blanket

1 Coat

1 Rain Poncho

1 Pair of adequate shoes (not new and not worn out)

3 Pairs of socks

2 sets of underclothing

2 Bandanas or neckerchiefs

1 metal pie dish

1 fork and spoon

1 Tin cup

1 Toothbrush and toothpaste

1 Personal first aid kit (chapstick, bug spray, sunscreen, band aids)

1 Set of scriptures

1 water bottle

Clothing (refer to the attached sheet)

Optional Camera

Pocket knife

Journal and pen or pencil

Begin preparing physically . . . This isn’t just a walk in the park, break in those hiking shoes. You should begin walking several

times each week. Challenge yourself; hike up hills, bike, run, carry weights, exercise. Anything

you do to get ready physically will benefit you on the trek.

Remember—Warriors of the Truth

Ephrata Stake Trek June 21-24

Each Participant needs their own 5-gal bucket with lid, to put the following items in: (note: plate = pie

pan) Metal dishes, bug spray, chapstick, comb, bandaids, toothbrush/paste, needed medication,

sunscreen, scriptures, journal, extra shoes, rain poncho, hat, bandana, water bottle, extra clothes,

underclothes, and 5 socks & gloves. (PJ’s can be in your bedroll) Optional: camera, pocketknife. Also,

you will need a bedroll that includes: Sleeping pad, sleeping bag, blanket, pajamas, and coat for

evenings – preferably all layered and rolled up into one bed roll, and in garbage bag – label it!

YOUNG WOMEN TREK CLOTHING 2 mid-calf length, long-sleeve dresses OR 2 mid-calf-length skirts and 2 lightweight, long-sleeve blouses 1-2 bonnets or straw hats 1 pair of bloomers OR leggings/long shorts for under skirt/dress to help prevent chafing 1 apron 4-5 pairs of not new or worn-out pairs of socks 1-2 good pairs of good walking shoes (NOT NEW) 1 pair of water shoes 1 pair of work gloves 2-3 sets of underclothing/underwear 1 set of pajamas/sleepwear 2 bandanas or neckerchiefs 1-2 plain-colored sweatshirts, sweaters or jackets OR a warm shawl for cooler weather. (Please NO designs, pictures or words on them.)

YOUNG MEN TREK CLOTHING 2 pairs of wool, canvas or cotton pants (NO LEVIS) 2 lightweight, long-sleeved, button-up shirts (NO COLLAR PREFERRED) 1 wide-brimmed hat (NO BASEBALL OR ARMY HATS) 1 pair of suspenders OR a belt 2-3 sets of underclothing/underwear 1 set of pajamas/sleepwear 1 pair of work gloves 4-5 pairs of not new or worn-out pairs of socks 1 pair of broken-in boots OR a good pair of walking shoes (NOT NEW) 1 pair of water shoes 2 bandanas or neckerchiefs 1-2 plain-colored jackets, vests or sweatshirts for cooler weather (Please NO designs, pictures or words on them.)