Gila Log - March 2006

2006 W5A Section Conclave
Individual Registration Form
Dates: Friday, Saturday, and Sunday, April 7, 8, and 9, 2006
Location: Philmont Scout Ranch, Cimarron, New Mexico, USA

Service Lodge: Yah-Tah-Hey-Si-Kess Lodge, #66, Great Southwest Council, BSA
Purpose: Fun, training, fellowship, fun, competition, sharing, motivation, fun.

Name: ____________________________________ Address: __________________________________________
City: __________________________ State: ____________ Zip: ________ Telephone: ______________________
Date Of Birth: ________________ Lodge: __________________________________________________________
Rank (youth) or Position (adult) _____________________________________ Ordeal / Brotherhood / Vigil (circle one)
Youth or Adult _________ Male or Female __________ Signature: ______________________________________
E-Mail ______________________________________________________________________________________
Total Enclosed: $ __________ Cash ______ Check # ____________ Please make check payable to:
                                                                                   Yah-Tah-Hey-Si-Kess Lodge, BSA
Credit Card MC/VISA/AMX Card # _______________________________________ Expire Date ____/______
Signature ________________________________________________ Date _________________

Registration Fees: ____ Early $45 (before March 7, 2006) ____ Regular $50                                                         $ ________

Accomodations: ____ Bring Tent $0 ____ Buster Brown sleep on floor in room $4.00 per person/night                $ ________

___RV Parking ____ Cabin (2-5 beds per cabin) (first come, first served) $25 + $5 each additional person/night $ ________

                                                                                                               Total fees included $ ________

_______________________________________________Types of Registration:________________________________________________
Early Registration $45 if registered and postmarked by March 7, 2006
Regular Registration $50 if registered and postmarked after March 7, 2006 (& at the door)

_____________________________Types of Housing (bring your own bedding/sleeping bags):_________________________________

Bringing Tent: No additional fee due for camping in your own tent around tent city. Use PTC shower facilities.
Buster Brown Room: $4.00 extra per person per night. You sleep on floor in a large conference room. PTC Showers.
Cabins: $25 per night, plus $5/night each person after the first. Sleep 2-5 per cabin. Showers in cabin. (1st come, 1st served)

Register Today! Send this form with your payment to the host council: Yah-Tah-Hey-Si-Kess Lodge

Great Southwest Council, BSA

For information, contact: Joey Dworak OR David Panko 5841 Office Blvd NE

915-494-1000 915-845-7702 Albuquerque, NM 87109

joeyd4585@aol.com gilaboy@elp.rr.com PH: (505) 345-8603 or 1-800-368-9218

FX: (505) 345-4201

All participants under the age of 18 (DOB after 04/01/90) must complete the Medical & Permission Form below. Other participants should complete to ensure their medical history is available if needed.

Parent’s Name _________________________________________ Address ______________________________________________________

City _____________________________________ State ________________ Zip _________ Telephone (home #) _______________________

Telephone (work #) ________________________________________ (emergency #) ______________________________________________

Family Physician _____________________________________________________ Telephone ______________________________________

Health Insurance ________________________________________________________ Policy No. ____________________________________

Date of immunization for tetanus toxoid ___________________________________________________________________________________

Any condition that may require special care? _______________________________________________________________________________

Any condition now requiring regular medication? ____________________________________________________________________________

Any special dietary requirements? _______________________________________________________________________________________

Any restriction of activity for medical reasons? ______________________________________________________________________________

PARENT AUTHORIZATION

This health history is correct so far as I know, and the person herein described has my permission to attend the event described above and to engage in all prescribed activities, except as noted by me. In the event I cannot be reached in an emergency, I hereby give my permission to the physician, selected by any adult leader in charge, to hospitalize, secure medical care and proper anesthesia, or to order injection for my son.

PARENT SIGNATURE ________________________________________________________________ DATE __________________________

		On This Page:	Conclave Registration Form
				Volume: Volume 56 Issue 4 Page 9