STRONG WINGS ADULT EXPEDITION

PRESIDENTIAL TRAVERSE
August 4 - August 8, 2008

Please fill in all fields.
After printing, please sign where indicated and return with deposit.
   


Name


Age
DOB
M/F

Mailing Address   (Street)
(PO Box)

(City)
(State)
(Zip)

Home Phone
Work (Cell) Phone		  

Email		  

Family Physician   (Name & Phone)
Dentist   (Name & Phone)

Allergies
Current Medications

Special Conditions

Health Insurance
Address/Phone

Subscriber		 Certificate #
Group #

In case of emergency please contact:

#1     #2     #3

Name     Name     Name

 

I hereby give my authorization to the Staff of Strong Wings, Inc. to arrange for routine or emergency medical care and treatment in the event of injury and verify that I am in good physical condition for the participation in the Adult Expedition, August 4th thru August 8th, 2008. 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.
Signed __________________________________________  Dated ___________________
 


Strong Wings may use my unidentified photo in their brochures and literature, including their website.  yes  no

 

Members receive significant discounts on programs and events throughout the year.
Memberships are annual and run from September 1 thru August 31.
Please begin or renew my Strong Wings Membership   
$50 Single Membership    $100 Family Membership

Method of Payment:  Check      Visa       MasterCard

Amount Enclosed    (Thank You)

 

Credit Card #    Exp Date

Signature________________________________  Date_____________


 

Mail or Fax to:  Strong Wings . PO Box 2884 . Nantucket . MA . 02584    (508) 228-6348

© Strong Wings 2000-2008