MITOC Fall Circus'99 Signup Form for MITOC Members

CONTACT INFO:

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

TRIP INFO & INTERESTS:

This information is used to plan and guide the trip leaders on the interests of the group.

Dietary Restrictions
Activity	Interested?	Proficiency
I would like to hike	YesNo	Beginner Intermediate Advanced
I would like to Canoe	YesNo	Beginner Intermediate Advanced
I would like to climb	YesNo	Beginner Intermediate Advanced
Other Interests

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?

MEDICAL:

Please list allergies or medical conditions you have:
(none)

Do you have medical training? No

Yes -- what level?

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