Pioneer Handcart Trek 2026 | Crescent View Stake

Participant Information

Full Name *

Date of Birth *

Unit *

Sex *

Address *

City *

State/Province *

Phone Number *

Emergency Contact Name *

Primary Phone *

Secondary Phone

Does the participant require a special diet? *

YesNo

Does the participant have any allergies? *

YesNo

List all prescription or over-the-counter medications the participant is currently taking. Leave blank if none.

Can the participant self-administer his or her medication? *

YesNoN/A

If no, please contact Nate Littlefield(email|phone)

Does the participant have a chronic or recurring illness? *

YesNo

Has the participant had recent surgery or a serious illness in the past year? *

YesNo

Identify any other limits, restrictions, or disabilities that could prevent the participant from fully participating in the event or activity.

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Printed Name *

Date *