Trek 2017: Registration
This form must be completed by March 26, 2017. Each participant (adult and youth) must complete and submit this electronic form, PLUS PRINT AND SIGN the Standards and Release form (bit.ly/trek2017release). Please submit the signed paper release to your unit YM or YW presidency leaders (again, on or before March 26, 2017).
First Name *
Your answer
Last Name *
Your answer
Preferred Name / Nickname *
Your answer
I am a: *
Birth date *
MM
/
DD
/
YYYY
Age as of first day of Trek (June 19th) *
Grade Fall 2017 *
Ward *
Address Information
Street *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Youth Email
Your answer
Youth Phone/Cell
Your answer
Parent / Guardian Info
Parent / Guardian Name *
Your answer
Parent / Guardian Email *
Your answer
Parent / Guardian Home Phone *
Your answer
Parent / Guardian Cell *
Your answer
Family Preferences
First and second choice of friends you would like in your Family:
1. Name
Your answer
1. Ward
1. Age
2. Name
Your answer
2. Ward
2. Age
If you're not a member of The Church of Jesus Christ of Latter-Day Saints, or a member not from the Moscow Stake, please note who you'll be attending with:
Your answer
Health History
Please be thorough as you complete this section of the registration
Have you had more than a minor illness or injury during the past year?
If you checked "Yes" above, please explain:
Your answer
If you currently suffer from, or have experienced any of the following conditions within the past year please mark the appropriate space below.
If you marked ANY of the above items, please explain:
Your answer
Please check any of the following that apply to the participant
If you marked ANY of the above items, please explain:
Your answer
Medications currently being used:
Your answer
Are Immunizations up to date? *
Date of Last Tetanus Shot
MM
/
DD
/
YYYY
Insurance Information
Primary Physician Name *
Your answer
Phone *
Your answer
Medical Insurance *
Your answer
Policy Number *
Your answer
Standards & Release
One last time: each participant (adult and youth) must complete and submit this electronic form, PLUS PRINT AND SIGN the Standards and Release form (bit.ly/trek2017release). Please submit the signed paper release to your unit YM or YW presidency leaders (again, on or before March 26, 2017).

YOU PRINTED AND SIGNED THE FORM, RIGHT? :)

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