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SCHEDULE Reservations Area Info.
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CKAPCO / Antietam Creek, Greg Mallet-Prevost
1. Class/trip description and Date(s)_______________________________ Name ____________________________________ Date of Birth ___________________Address ______________________________________________________________________Street City State ZIP Telephone number(s) ____________________________________________________________Home Work Other E-mail addresses) ______________________________________________________________ Home Work
Background I am taking this course because____________________________________________
Briefly describe your paddling experience: _________________________________________________________________________________________________________________________ Approximate height and weight ____________________________________________________________________________
Please rate your swimming ability: none weak good strong
Confidential Medical and Emergency Information Emergency contact ___________________________________________________ Name____________________________________________________________________________ Telephone Number Relationship to you Please list any medications you are taking: _____________________________________________Do you have any medical conditions we need to know in case of emergency? ____________________If so, please explain: _____________________________________________________________Please indicate any medical or environmental allergies: ____________________________________Do you have any physical limitations that could affect your participation in the course? ______________If so, please explain: _____________________________________________________________Signature and date please.
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GMP/T&E SYS INK. |