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Pack, Paddle, Ski -Journeys of Inspiration

2008 Program Registration 

Because we like to talk to anyone registering to answer any questions and to get to know you a little, please call us week days at (585)346-5597 between 10:00 am and 3:00 pm EST.  We can quickly get your registration and credit card (VISA or Master Card) deposit information.

Other ways to register would be:  Please fill out the appropriate information below and send it with your registration fee to: Pack, Paddle, Ski; P.O. Box 82; South Lima, NY 14558-0082 Or E-mail us at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

NAME_____________________________________________________________________

ADDRESS__________________________________________________________BOX NO. /APT _______ _

CITY________________________________________________STATE_______________ZIP+4_________

DAY TIME PHONE______________________EVENING PHONE______________________

E-MAIL_______________________________________________________________

D.O.B.________SEX_______CONCERNS?___________________________________Y   N

Course Name:                                                               Amount $             Deposit Required

TOTAL ENCLOSED                   $______________

I have read and understand the refund policy (see General Information in this newsletter)

________________________________________________ Signature  ________________Date

PAYMENT METHOD  (CIRCLE ONE)

CHECK                       VISA                       MasterCard

____________________________________________________________________

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Card Account Number

|___|___| / |___|___|           

Month/Year           Expiration Date Required

________________________________________________ Signature  ________________Date

HEALTH INFORMATION

Doctor's Name: ___________________________________________________________

Phone Number:                                    Date of last physical _____________________

Health Insurance Company _________________________________________________

Policy Number _______________________

Any Physical Restrictions?                 Allergies?

Food Restrictions (be specific)

History of Heart/Respiratory Trouble?_____________________

Asthma?_________________Diabetes?_____________________

Medications currently being taken___________________________________________________Dosages__________________

Are you currently being treated for anything?______________________________________________________________________

Have you been treated for anything within the last 6 months?________________________________________________________

Average weekly physical activity (type/duration)___________________________________________________________________

EMERGENCY CONTACT

Name___________________________ Relationship________________

Phone (specify day/evening)_______