SU application

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Please print & fill out the form and send it with a cheque made out to 'SU Manuscript Discovery' to:

SU Manuscript Discovery
64 National Park Street
Hamilton South 2303

Costs:

$160.00 ............ adult (paid employment)

$145.00 ............ adult (unpaid)

$125.00 ............ high school student

$100.00 ............ infant & primary school student

$ ............ Total

Payment:

I enclose a cheque/money order for: $ ................

Signature ........................................ Date .... /.... /2002

Cancellation:

Deposit ($50) will be forfeited in the event of cancellation.

Name:

Age:

Address:

Postcode:

Phone:

e-mail:

Occupation:

Church attended:

Where did you hear about M.D. Camp? Friend / Church / Brochure / Internet / Other

Is this your first M.D. Camp ? yes / no

Registration and other information:

Name ................................................................................. M / F

Children attending: ............................................................. school year: .......

................................................................................... school year: ......

Health information:

Those attending will be responsible for their own health insurance, and will be themselves responsible in the event of any accident or misfortune that may occur to themselves or damage or loss to their property.

Is any person on a special diet? yes / no If so please give details

Describe in detail any allergies (drug, environment or food) and medication taken for each.

Describe in detail any other conditions and medication?

Emergency contact:

Name: .................................................................................

Phone: .................................................................................

Signature certifying acceptance of all conditions hereon:

Date:

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