New England Circle K

Circle K International

InterNECK Registration

Welcome to InterNECK 2009 Registration!

InterNECK is a fun-filled weekend with service projects, field games and activities, workshops, and a dance! This year's theme is PIRATES so bring your costumes for our dance. InterNECK will take place at Camp Mechuwana in Winthrop, ME from October 16-18, 2009.

Cost: $50 includes 4 meals (3 on Saturday, 1 on Sunday), lodging (but don't forget your sleeping bag and pillow!), snacks, and all workshop materials and games. Payments must be postmarked by October 9th, 2009. Checks should be made payable to New England Circle K (no cash) and should be mailed to:

Matt Dellea
Lammers Hall-RA
Westfield State College
577 Western Ave
Westfield MA 01086

Registration deadline is October 8th by midnight. No more late fees!

Fill out the form below and we'll see you at InterNECK!

Part I: Registration Form*Name *School *Position Held *Are you a first year/new CKI member? *E-mail *Address (Street, City, State, Zip) *Phone *Food Restrictions (e.g. allergies, vegetarian, etc.) *Other Special Needs (e.g. facilities, etc.) Part II: Medical Questionnaire/Emergency Medical Treatment Authorization*Name *Height *Weight *Sex
Male Female *Address (Street, City, State, Zip) *Emergency Contact Person *Relationship to you *Emergency Contact Home Phone *Emergency Contact Work Phone *Alternative Emergency Contact Person *Relationship to you *Alternative Emergency Contact Home Phone *Alternative Emergency Contact Work Phone *Doctor's Name *Doctor's Phone *Doctor's Address (Street, City, State, Zip) *Health Insurance Company *Health Insurance Policy Number *Any other pertinent information on the card *List any medications you will be taking during the weekend Have you been treated for any of the following (Check all that apply)
Nervousness
Any mental disorder
Convulsions or Epilepsy
Fainting Spells
Heart Condition
Rheumatic Fever
Cancer or Tumor
High Blood Pressure
Severe or Frequent Headaches
Asthma
Ulcers
Diabetes
Allergic reaction to medication
Any other allergies or illnesses?
*Do you have any physical limitations?
Yes No If you answered yes to any of the above questions, please give details of treatments, dates, physicians, hospitals, and clinics below.
PLEASE READ CAREFULLY (Treatment Agreement)

I hereby certify that the information given above is correct. In case of medical emergency, I understand that every effort will be made to contact the person designated above. In the event that person cannot be reached, or time does not permit, I hereby give permission to a licensed physician to provide proper treatment.

*Treatment Agreement Signature (Please Initial) *Date