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________