STRONG WINGS AFTER-SCHOOL PROGRAM
Spring 2008

Please fill in all fields. After printing, please sign where indicated.
(ACCEPTED BY MAIL ONLY WITH APPLICABLE FEES)

Child's Name
Age    DOB     M/F    Grade
School
Parent(s) Name
Mailing Address
 
Home #  Work #  Cell #
Family Physician
Dentist
Child's Allergies
Special Conditions
Medicines Child is Taking
Health Insurance
Address/Phone
Subscriber
Certificate #    Group #
In case of emergency we can be reached at one of these numbers:
#1     #2     #3

I hereby give my consent for my child to participate in Strong Wings, including rock-climbing and further give my authorization to the Staff of Strong Wings, Inc. to arrange for routine or emergency medical care and treatment necessary to preserve the health of my child. I acknowledge that I am responsible for all reasonable charges in connection with care and treatment rendered and agree not to hold Strong Wings, Inc. or any member of their staff responsible in the unlikely event of an accident.

I have read all rules and regulations and agree to adhere to them.

Signed
________________________________  Date _____________
 

Member $80       Non-Member $120
Individual Membership $50    Family Membership $100  (9/1-8/31)
I would like to make a donation in the amount of $
 

Total Amount Enclosed    (Thank You)

Check Enclosed       Visa       MasterCard

Credit Card #    Exp Date
Signature________________________________  Date_____________

Mail To:  Strong Wings . PO Box 2884 . Nantucket . MA . 02584

© Strong Wings 2000-2008