Registration and deposit for the summer tour:
If you are interested in joining us for the summer tour please register and provide a deposit (non-refundable unless we cancel the tour) of $125 payable online or by check made out to the AEYF and sent to 61 Westview Road, Worcester, MA 01602. The sign up deadline is April 14, 2008. If we do not have enough people signed up by April 14th the deposit will be fully refunded.
AEYF Summer Tour
June 29th-July 3, 2008
California
Medical Release Form
Name________________________________________________________________________________
Birth Date________ /________ /________________ (MM/DD/YYYY)
Address________________________________________________________________________________
City_________________________ State________________ Zip/Postal Code_____________________
Cell Phone (_________ )_________ -________________ E-Mail Address __________________________
Father's Name____________________________________ Phone (_________ )__________ -________________
Mother’s Name____________________________________ Phone (_________ )__________ -________________
Name and Phone of other Relative or Neighbor if parents cannot be reached.
Name____________________________________ Phone (_________ )__________ -________________
Family Doctor____________________________________ Phone (_________ )__________ -________________
For this Period June 29-July 3, 2008 we authorize Rev. Ara Jizmejian or his designated alternate to obtain emergency medical treatment for the individual listed above, including hospitalization, injections, anesthesia or surgery.
Important medical information (medicines being taken, allergic reactions to any medication, important medical history.):
Insurance Carrier___________________________________________________________________________
Policy #___________________________________________________________________________
Signature of Participant_________________________________________________________________
Date______ /______ /_____________
Signature of Parent or Guardian_________________________________________________________________
Date______ /______ /_____________