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1999 COLONIAL SPRING ORDEAL REGISTRATION FORM

 

By April 30 1999, mail this completed form with your check to:

Order of the Arrow

National Capital Area Council

9190 Wisconsin Avenue

Bethesda, MD 20814

Please print all information. One form per individual. Each participant must have a completed form. Please copy as necessary.

Name___________________________Age____Chapter_____________Phone_______________

 

Address_______________________________________________________________________

Unit Type: Troop/Post/Dist/_______ Unit Number______ Date of Birth:(dd/mm/yr)________

1. PARENTS AUTHORIZATION FOR ALL SCOUTS UNDER 18 YEARS OF AGE

I,___________________________, parent/guardian of the above named member of the Amangamek-Wipit Lodge, a minor, in the event of illness occurring to the member during his visit to, at and from Camp Snyder from 14-16 May 99, do hereby consent in advance to whatever medical procedure or treatment is considered necessary in the best judgement of the attending physician. I understand that, in the event of serious illness or injury which is not an emergency, reasonable efforts to reach me will be attempted.

___________ __________________________________ ____________________________

Date Parent/guardian signature Phone Number

_________________________________________________________________

Street, City, Zip

2. MEDICAL INFORMATION

a. Physical Limitations:__________________________________________________

b. Conditions which now require regular medication, name of medication and frequency and amount of dosage:

_______________________________________________________________________

c. Special dietary needs:_________________________________________________

d. Medical insurance company/policy:______________________________________

3. EMERGENCY NOTIFICATION INFORMATION: in case of emergency, please notify

_____________________________ ______________________ _________________________

Name Relationship Phone Number

______________________________________________________________________________

Street, City, Zip

4. Registration fees are as follows (Account 1-2371-315-00):

5. Member $18.00 _____

Brotherhood Conversion $30.00 _____

Ordeal Candidate $35.00 _____

Elangomat $13.00 _____

Saturday Only $11.00 _____

TOTAL AMOUNT ENCLOSED __________

5. SIGNATURE IF OVER 18 YEARS OF AGE:___________________________Date________