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Name:
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____________________________________________ |
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KMC Member:
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Yes/No |
| I am 19 years or older: | Yes/No If No, a parent or guardian must sign a waiver. |
| Home Phone #: | _____________________________ |
| Email Address: | ____________________________________________ |
| Home Address: | ____________________________________________ |
| ____________________________________________ | |
| ____________________________________________ | |
| Emergency Contact: | ____________________________________________ |
| (Name + Phone Number) | ____________________________________________ |
| Pertinent Medical | ____________________________________________ |
| Conditions: | ____________________________________________ |
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To apply for the 2005 KMC Introduction to Mountaineering Course, complete the above form, and mail it along with a non-refundable deposit of $100: Sandra McGuinness Make cheques payable to the KMC. |
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