Name _______________________________________________
 
Date of Birth __________ Phone____________

Address _____________________________________________ 

City ______________ State ___ Zip _______

Troop/Post # ________ (or District Scouter position)
Chapter ___________________________

Parental Authorization for Scouts under 18 years of age:

I, ____________________________, Parent/Guardian of

scout__________________________, a minor, authorize in 
advance, whatever medical treatment may be necessary 
in the judgement of an attending physician due to 
illness or accident.  I understand that every reasonable
effort will be made to contact me.

Date _________ 

Signature of Parent/Guardian____________________________

Medical Information:

a. Physical Limitations  ________________________________

b. Medications (name, dosage, frequency) ________________

   ______________________________________________________

c. Special dietary needs ________________________________

_________________________________________________________

d. Medical Insurance 

   Company________________________________________________

   Policy No. ____________________________________________

Emergency Contact:

Name              ______________________________ 
Relationship      ______________________________
Phone             ______________________________  
Alternate Phone   ______________________________
Address           ______________________________

Transportation: I can provide a ride for ______ others.
                I need a ride (YES/NO)______.

Registration Fees: Make checks out to "NCAC-BSA." 
Payable on arrival.

___$20 per person (includes Food, Lodging, Insurance).
___$30 Fellowship Fee plus Brotherhood Sash
___$20 Saturday Dinner and Brotherhood Sash
___$10 Saturday Dinner Only

Trading Post Items will be available during the Fellowship 
Weekend.

Mail completed form to:Winter 1999 Tri-Chapter Fellowship
(By January 29, 1998)c/o Mr. Philip Sternberg
P.O. Box 4052
Alexandria, VA 22303

Or you may email the form to:psternbe@osf1.gmu.edu
 

Date ________________ Signature __________________________