MITOC Acadia Signup Form

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, you will be reimbursed for gas. If you need to make special transportation arrangements (i.e., you need to leave at a different time from everyone else), please contact the trip leader.

MEDICAL:

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

Do you have medical training? No

Yes -- what level?

Form created and maintained by Greg Galperin, grg@ai.mit.edu