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Greater Pittsburgh Council Enda Lechauhanne Lodge #57 Boy Scouts of America

OA Winterfest Weekend 2009 Registration Form


January 30th, 31st, February 1st - 2009

Name: Membership Data


Youth Adult
Address:
Please check one above

City, State, Zip:


Mail To:
Home Phone #: Business/School Phone #: Enda Lechauhanne Lodge #57
Boy Scouts of America
Birth Date: eMail: 1275 Bedford Avenue
Flag Plaza
District: Unit #: Pittsburgh, PA 15219

MEMBERS By After NO Arrival & Check-In: Accounting 1-2371-996-00


1/15 1/23 Friday 6:00 PM to 9:00 PM
Check #:
Ordeal Member Registration Area:
Pathfinder Lodge Amount:
Brotherhood Member
Walk Receipt #:
$30.00 $40.00 In's
Date:
Check-Out & Departure:
Vigil Member Sunday 11:00 AM

You must be a member in “Good Standing” to attend


Dues may be paid at the event *1237199600*
Please mark your checks with the following account number >> 1-2371-996-00
Please take your time — PRINT LEGIBLY — and complete all sections accurately — Make checks payable to “GPC-BSA” …. Thank You

HEALTH HISTORY
PLEASE ENTER AN “X” IN THE BOX IF YOU HAVE OR ARE SUBJECT TO:
¨ Asthma ¨ Fainting Spells ¨ Convulsions ¨ Swimming Or Sports Restrictions
¨ Diabetes ¨ Heart Trouble ¨ Other (Describe Below) ¨ Allergies/Reaction To Medication (Describe Below)
Describe:

PLEASE ENTER AN “X” IN THE BOX IF YOU HAVE DIFFICULTY WITH:


¨ Diphtheria ¨ Sleepwalking ¨ Mumps ¨ Whooping Cough
¨ Lungs ¨ Digestion ¨ Measles ¨ German Measles
¨ Chicken Pox ¨ Bed Wetting ¨ Eyes, Ears, Nose, Throat

PLEASE ENTER AN “X” IN THE BOX AND COMPLETE THE FOLLOWING, IF APPLICABLE:
¨ Currently taking medication for: Name of medication:
¨ DID YOU BRING AN INHALER?
¨ Activity restrictions for medical reasons:

PLEASE PROVIDE IMMUNIZATION RECORD:


Date of last inoculation Date of last inoculation

Tetanus: Measles:
Polio: German Measles:
Mumps: Diphtheria:

APPLICANT AUTHORIZATION:
This health history is correct, as far as I know, and the person herein described has permission to engage in all prescribed activities, except as
noted. In the event I cannot be reached in an emergency, I hereby give permission to the physician, selected by the adult leader in charge, to hos-
pitalize, secure proper anesthesia, or to order injections for my son.

Applicant Parent
Signature: (If under 18): Date: