IOCA/MITOC Fall Lake George '99 Signup Form for MITOC Members

CONTACT INFO:

Name
Email
Phone
Emergency Contact Phone
Medical Insurance Company
Medical Insurance Policy No.

TRIP INFO:

Dietary Restrictions
Would you like to bring a bicycle? No
Yes

TRANSPORTATION:

I have a car I'm willing to drive. It holds people including the driver,
       canoes and bicycles.
I'm 25 or older and I'm willing & able to drive a van rented by MITOC.
I need a ride. Will you please find me one?

Note that if you drive, each passange will give you $10 for gas and tolls.

MEDICAL:

Please list allergies or medical conditions you have:

Do you have medical training? No
Yes --  what level? 

Form created Greg Galperin. If you have problems, contact hbriceno@mit.edu