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ABTC BOOKING FORM Badge……………………………………. Date of weekend ……………………….. Cost… ……………………£25.00 Name..……………………………………………..D.O.B……….…………………. Address..……………………………..………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. Post code..………………………………Tel no..………………………………….. Scout Troop………………………………………………………………………….. Scout Leader……………………….………………………………………………… Emergency contact………………………………………….………………………. Address (if different from above)…………………………………………………… …………………………………………………………………………………………. …………………………………………………………………………………………. Tel no (day)……………………………………(night)………………………………. MEDICAL DETAILS Doctor's name………………………………………………………………………. Address…………………………………………………………………………….… …………………………………………………………………………………………. Tel no..……………………………………………. Do you suffer from Asthma, chest complaints, hay fever, diabetes, epilepsy or any illness / ailments? YES / NO If Yes give details…………………………………………………………………….. ………………………………………………………………………………………….. Medicines currently taking (including inhalers)……………………………………. ………………………………………………………………………………………….. Are you allergic to anything (food, antibiotics etc)? YES / NO If Yes give details…………………………………………………………………….. ………………………………………………………………………………………….. Do you have a mobility problems? YES / NO If yes give details……………………………………………………………………... ………………………………………………………………………………………….. If it becomes necessary for…………………………………. to receive medical treatment and I cannot be contacted by telephone or any other means to authorize this, I hereby give my consent to any necessary medical treatment and authorize the Leader in Charge of the Group to sign any documents required by the hospital authorities. Signed……………………………………………………Date………………………. Please return to Rikki at Hesley wood


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