2009 Winter Fest Registration Form

Greater Pittsburgh Council

Enda Lechauhanne Lodge #57 OA Winterfest Weekend 2009 Registration Form

Boy Scouts of America

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

Name:

Youth

Address:

Adult

Please check one above

City, State, Zip: Home Phone #:

Business/School Phone #:

Birth Date:

eMail:

District:

Unit #:

MEMBERS

By 1/15

After 1/23

NO

Ordeal Member Brotherhood Member

Walk $30.00

$40.00

Mail To:

Enda Lechauhanne Lodge #57 Boy Scouts of America 1275 Bedford Avenue Flag Plaza Pittsburgh, PA 15219

Arrival & Check-In: Friday 6:00 PM to 9:00 PM

Accounting 1-2371-996-00 Check #: Amount: Receipt #: Date:

Registration Area: Pathfinder Lodge

In's

Vigil Member

Check-Out & Departure: Sunday 11:00 AM

*1237199600*

You must be a member in “Good Standing” to attend Dues may be paid at the event

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 ¨ Diabetes ¨ Heart Trouble ¨ Other (Describe Below)

¨ Swimming Or Sports Restrictions ¨ Allergies/Reaction To Medication (Describe Below)

Describe: PLEASE ENTER AN “X” IN THE BOX IF YOU HAVE DIFFICULTY WITH: ¨ Diphtheria ¨ Sleepwalking ¨ Mumps ¨ Lungs ¨ Digestion ¨ Measles ¨ Chicken Pox ¨ Bed Wetting ¨ Eyes, Ears, Nose, Throat

¨ Whooping Cough ¨ German Measles

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 hospitalize, secure proper anesthesia, or to order injections for my son. Applicant Signature:

Parent (If under 18):

Date: