Eastmark Stake Trek 2025

Permission and Medical Release Form

We are so excited for you to join us for the Mesa Arizona Eastmark Stake Pioneer Trek 2025 happening on May 28 - May 31, 2025. Trek is being led by Todd and Kara Bowman. Please contact them with any questions at:
Phone: 480-980-0027 or 480-980-6901 or Email: karabowman@cox.net

Participant Details

Participant Type

Ward

Please provide a recent headshot photo

Personal Information

First name

Last name

Date of birth

Phone number

Email address

Address line 1

City

State

Emergency Contact Information

Emergency contact first name

Emergency contact last name

Emergency contact primary phone number

Emergency contact secondary phone number (optional)

Medical Information

If you checked "Yes" to any of the above conditions, please explain

If you are a youth - Have you EVER had a significant illness, injury, or any surgery, or hospitalization? If you are an adult just report on anything in the last year Yes No

Describe any allergies to medications, food, plants, insects, etc

Medications currently taken on a daily or as-needed basis (include prescription and over-the-counter medications):

Is your child able to self-administer their own daily prescription or over-the-counter medications? Yes No

Do you authorize Adult Leaders to give your child Over-the-counter medications for aches, pains, upset stomach, etc, if your child requests it? Yes No

Is your child up-to-date on their school immunizations? Yes No

Date of last tetanus booster

Is a special diet needed? Yes No

Are there other accommodations or special needs that we should be aware of?

Conduct at Church Activities

Church events and activities can be fun, uplifting, and spiritually strengthening for everyone who attends. To reach these aims, all participants are invited to commit to follow the principles taught in For the Strength of Youth: A Guide for Making Choices. When you do, the experience will be better for everyone. Please note that Church activities are not the time or place for romantic behavior or for conversations and actions that distract from the purpose of the event or activity. If you participate in any of the following prohibited activities, leaders at the event or activity will speak with you, your parents, and your bishop or stake president. These leaders may decide to send you home immediately.

Participating in or encouraging immoral behavior of any kind, which includes breaking the law of chastity or viewing or distributing pornography in any form
Shoplifting, theft, or vandalism of any kind
Breaking the Word of Wisdom, including vaping and possessing illegal or harmful substances
Possessing weapons or dangerous items of any kind (if specifically authorized, certain items may be provided and used in supervised activities)
Harming or threatening to harm yourself or others physically, spiritually, or emotionally, including bullying in any form or disrupting another’s experience
Leaving without following proper procedures, skipping scheduled activities without permission, or breaking curfew

Crimes and harmful or destructive incidents or pranks may be reported to local authorities, who will respond according to local law. Leaders follow the direction of these authorities.

Permission

I give permission for my child or youth to participate in the event and activities listed above (unless noted) and authorize the adult leaders supervising this event to administer emergency treatment to the above-named participant for any accident or illness and to act in my stead in approving necessary medical care. This authorization shall cover this event and travel to and from this event. Please note: Units may not have the ability to meet all medical, physical, and other accommodations and are asked to counsel with parents or guardians on what is possible. The participant is responsible for his or her own conduct and is aware of and agrees to abide by Church standards, camp or event safety rules, and other pertinent instructions. The participant's conduct and interactions should abide by Church standards and exemplify Christlike behavior, including those listed on the attached “Conduct at Church Activities.” Parents and participants should understand that participation in an activity is not a right but a privilege that can be revoked if participants behave inappropriately or if they pose a risk to themselves or others. This information is collected to help event and activity leaders or medical personnel so they can be prepared and appropriately respond to health concerns or an emergency. It will be kept confidential and shared only as needed.

Participant signature

Parent signature