Fun Day Registration Form 2009
please copy and paste for your use (reset all margins to .5 then the form will fit on one page
Youth Outdoor Fun Day Registration Form Name of Participant: First: __________________________Last:____________________________ (Please Print) Address_________________________________ Town/City: ___________________ Province: _________________Postal Code_____________________ Birth date: _________________Age_____________ Sex: M F D/M/Year Parents’ Name & Work Telephone ______________________________________________ Home Telephone_____________________ Cell Phone (if available):____________________ Health Care Number_______________________________________________ Blue Cross Number (if you have one)__________________________________ Family Doctor: ___________________________________________________ Please check off any conditions that may apply to you: o Asthma o Bone/Muscle o Diabetes o Arthritis o Epilepsy o Cramping o Heart Problems o Nerves, Anxiety o Lung Problems o others (Please Specify) _______________________________ ________________________________________________________________________ Are you allergic to anything? Please be specific, including required treatment. List all Medications you need to take between 8 AM and 6 PM. All required medications must be brought in original pharmacy containers correctly labelled with doctor’s name and instructions. In case of a medical emergency I understand every effort will be made to contact me. If I cannot be reached, I give my permission to any physician selected to secure necessary treatment, including hospitalization. To the best of my knowledge, my child is in good health. I understand also that if my child refuses to abide by the rules of the organizers that I will need to come immediately to pick him/her up from the site. Signature of Parent or Guardian Date ___________________________________________________________________________ Signature of Participant Date Has the participant attended the Youth Fun Day before? Yes No
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