FLOAT TUBE ADVENTURES REGISTRATION FORM 11231 S.W. 95th Ave Tigard, OR 97223 fishon@floattubefishing.com 503-880-4517 www.floattubefishing.com Please type or print - *Make extra copies for additional students -- One form per child, please.* Student's name___________________________________________ Age_____ Date of Birth_______________ Sex_____ Address_____________________________________________________________________________________________ City_________________________ State____________________ Zip_____________ Home Phone___________________ Dates of Attendance *(be specific)________________________________________________________________________ Mother's Name_________________________________________ Occupation___________________________________ Home Phone___________________________________________ Employer_____________________________________ Work Phone__________________________________ Father's Name__________________________________________ Occupation___________________________________ Home Phone___________________________________________ Employer_____________________________________ Work Phone__________________________________ I am enclosing registration fees ($10.00) with this registration in order to reserve a placement in the program, and agree to full payment of tuition prior to session. (Please write child's full name & age on check.) Signature___________________________________________Date____________Amount of Payment___________ • • • • • • • • • • • • • • • • • • • • • • Hospital EMERGENCY CONSENT FORM To protect your child in the event of a medical emergency , if you aren’t available to give formal consent to medical authorities, this completed and signed form will accompany your child to the hospital so that medical treatment can be rendered. I/we hereby authorize FLOAT TUBE ADVENTURES STAFF to give consent for all medical and/or surgical treatment that may be required for our child/children during our absence, from (Dates of Summer Session) Allergies or Medical Problems__________________________________________________________________________ Chronic Illnesses__________________________________ Current Medications_________________________________ Date of Last Tetanus Immunization____________________________ Other______________________________________ Emergency Contacts Name_________________________________________________ Relationship______________ Phone______________ Name_________________________________________________ Relationship______________ Phone______________ Nearest Relative_________________________________________________________________ Phone______________ Doctor________________________________________________________________ Phone_____________________ Health Insurance Co.:_________________________________ Member #_____________________Group #__________________ Signed, parent/guardian:_____________________________________________________ Date_____________________