2007 Conclave Delegate Registration Form

Conclave Dates: April 20-22, 2007 Location: Camp Durant, Carthage, NC

Form Due: March 1, 2007 Lodge 70 – Tsoiotsi Tsogalii

Delegate Information

Name:

Chapter:

Email: Phone:

Address:

City: State: Zip:

Birthdate (MM/DD/YYYY):

Circle One:
Ordeal Brotherhood Vigil

Special Dietary Needs (describe below):

Do you require special needs for physical facilities during Conclave? (describe below):

2007 LODGE 70 CONCLAVE DELEGATE FEE: $30

RETURN COMPLETED DELEGATE REGISTRATION FORM, MEDICAL FORM, and PAYMENT TO:

Old North State Council

Attn: 2007 Conclave Registration

P. O. Box 29046

Greensboro, NC 27429-9046

RETURN ALL FORMS AND PAYMENT BY MARCH 1, 2007 TO RESERVE YOUR SPOT WITH THE LODGE 70 DELEGATION

2007 Conclave Delegate Medical Form

Due: March 1, 2007 Lodge 70 - Tsoiotsi Tsogalii

To be filled out by parent/guardian or adult participant. Please print in ink.
Delegate Information
Name:		Email:
Address:
City:	State:			Zip Code:
Phone: ( )				Date of Birth:
Circle One: Ordeal Brotherhood Vigil
Primary Emergency Contact
Name: Relationship:
Day Phone: ( ) Night Phone: ( )
Secondary Emergency Contact
Name: Relationship:
Day Phone: ( ) Night Phone: ( )
Medical Information
Do you: ___ have any medical restrictions? ___ currently take any medication? ___ have any dietary restrictions?					Explain:
Health Insurance Company:					Policy #:
Have or subject to: ___ Convulsions ___ Asthma ___ Fainting Spells ___ Bleeding disorder ___ Diabetes ___ Heart trouble ___ Allergy to medication, food plant, animal, or insect ___ Any condition requires special care, medication, or diet ___ NONE OF THE ABOVE APPLY					Explain:
Have difficulty with (check if yes): ___ Eyes, ears, nose, throat ___Digestion ___ Bed-wetting ___Lungs ___Sleepwalking					Explain:
___ Any condition now requiring regular medication?					Name of medication:
Last Tetanus toxoid date:
This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted. In the event that 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 injection.
Participant			Parent or guardian
Signature: x___________________________ Date: __________			Signature (if participant under 18 years): x_______________________________ Date: __________