Kent Stake Youth Trek 2015 Logo - Courtesy of Heather Froisland Kent Stake Pioneer Trek
July 15-18, 2015

Adult Registration Form
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All adults attending Trek should complete this form. Bing Canyon, WA
All fields with a red asterisk * between the text label and input fields are REQUIRED. If the requested information does not apply to you, please enter the text 'NA' or 'none'.
Participant Information
for help with registration data requested, mouse-over the associated label below
First Name:  *
Last Name:  *
Birth Date:  *   /    / 
Are you female or male?  *
Please Specify Your Home Ward/Branch:  *
In what capacity are you attending Trek?  *
Participant Email Address:  *
Participant Mobile Phone:
Note: Please use one of the following phone # formats: 000-000-0000, 000.000.0000, (000) 000-0000, 0000000000
Street Address:  *
City:  *
Kent | Covington | Auburn | clear
State:  *
Postal Code:  *
Note: Please include dashes for US 9 digit zip codes (ex. 10001-1001)
Home Phone:  *
Note: Please use one of the following phone # formats: 000-000-0000, 000.000.0000, (000) 000-0000, 0000000000
Statement of Responsibility:
This youth pioneer trek activity will be held in a wilderness setting. We will be “roughing it”, so to speak. The Stake will provide adequate food, restroom facilities, safe drinking water, and educational activities. Each participant in this trek must act in accordance with Church standards at all times (as established in the "For the Strength of Youth" pamphlet), and aid other members of the company in behaving in accordance with Church standards. There are inherent risks involved in all outdoor activities, including this Stake sponsored youth pioneer trek, which are beyond the control of the Stake staff and officers. Proper preparation reduces these 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 repellant, and other items listed on the personal equipment list. All participants must act in such a way as to not endanger themselves or others, and should show charitable consideration to all other participants and leaders participating in 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 three (3) miles on level ground in 60 minutes or less without undue stress or strain.

The Trek will be conducted on private property near Plymouth, WA. Each participant must follow applicable "Leave No Trace" camping protocols to maintain the wilderness nature of the property. Especially, each participant must avoid littering of any kind.
Medical Information & History
Please answer the following questions thoroughly.
List any medications you are allergic to:  *
List routine medications & current dosage:  *
Enter the date of your last tetanus shot:  *   /    / 
Past or current medical conditions:  *















Please add details or explain other conditions:
If you marked any of the above items, we recommend seeking medical advice to ensure participation will not adversely impact your health or safety. Participation is voluntary and is at the discretion the attending adult.
List physical conditions that limit activity:  *
Have you had surgery or a serious illness in the past year, or a chronic/recurring illness?  *
If yes above, please explain:  *
Food allergies or special dietary needs:  *
Doctor Name:  *
Doctor Phone:  *
Note: Please use one of the following phone # formats: 000-000-0000, 000.000.0000, (000) 000-0000, 0000000000
Insurance Company / Carrier:  *
Policy ID and Group Number:  *
Please list any other required information that may be needed for insurance purposes if it becomes necessary to secure the medical services of a doctor or hospital. This may include insurance preauthorization, phone numbers, name & policy number of the insured employee, whether it is necessary to contact a primary care physician, etc.
Additional Insurance Information:
Please be aware that the Church's insurance program, Church Activity Medical Assistance (CAMA) is primarily designed to supplement, not replace, a person's own health and accident insurance.
Note: If at all possible, family members will be contacted before securing the medical services of a doctor or hospital in the case of an emergency.
Permissions & Agreements
Participant Agreement
I declare that the above statements are complete and correct, and agree to act in accordance with the “Statement of Responsibility”. I also understand that I may be contacted with important trek-related information via email or text message (if mobile phone # provided). CHECK THE BOX TO CONFIRM  

Photography/Video Permission
I agree to be photographed and/or video to be taken of me for the use of the trek and other youth programs. CHECK THE BOX TO AGREE 
Having problems or have questions? kentstaketrek@gmail.com (general Trek-related questions)
registration@kentstakeyouthtrek.org (website-related questions or issues)
Once you have entered the requested information and provided the needed permissions, please click the 'Submit My Registration' button below. Upon successful completion, you will be sent via email a medical summary and agreement form in which each participant will need to date, sign, and return to your ward's YW or YM president. We look forward to seeing you on Trek!
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