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Allergy testing instructions

Asheville Integrative Medicine Allergy Testing Instructions 1. Complete the enclosed Allergy Questionnaire and bring this with you to your allergy evaluation appointment with a clinic physician. This important evaluation precedes the allergy testing itself. 2. As always, and in consideration of other clients and members of our staff who have unpleasant reactions to fragrances; please

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Medications and medical conditions FactsheetFoR FINANCIAl INTeRMeDIARIeS oNly. NoT APPRoVeD FoR uSe wITH CuSToMeRS. This guide lists approximately 1,700 of the most commonly prescribed medications and the principal condition(s) that each is prescribed for. The information is provided in connection with the principal condition(s) listed. This information is provided underwriting of annuities o

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Young Investigator Award / Best oral Award Presenting Author Affiliations A functional variant of SLC26A3 in association with ulcerative colitis down regulatesDepartment of Medicine and Clinical Science, GraduateSchool of Medical Sciences, Kyushu UniversityNFIL3 deficient mice develop IL-12/23 driven spontaneous colitisIBD center, Kitasato University Kitasato Institute HopspitalFecal

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Min Camino Min rejse mod pirgrimsvejen til Santiago de Compostela, Camino de Santiago, begyndte tilbage i 1998. På det tidspunkt i mit liv var jeg stille og rolig ved at åbne mig mod det spirituelle og åndelige i mit liv. Jeg var kommet til den mening at der er mere imellem himmel og jord end vi til daglig tager for givet. Jeg var begyndt at læse bøger som Den niende og den tiende indsigt

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Antibiotics 抗生素 PRODUCT NAME DESCRIPTION ß-Lactam Antibiotics Ampicillin Sodium Salt 50 μg/ml working concentration, interferes with formation of bacterial cell wall. Ampicillin Trihydrate 50 μg/ml working concentration, interferes with formation of bacterial cell wall. Carbenicillin Disodium Salt 0.1-30 μg/ml, synthetic derivative of Penicillin. Penicil

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ACKNOWLEDGEMENTS The Technical Working Group wishes to acknowledge the valuable contribution made by Professor Pieter Treffers and Mrs Petra ten Hoope-Bender in preparing a background paper for the meeting. The Technical Working Group also wished to thank the following participants for their presentations during the meeting: Dr Raj Baveja, Mrs Stella Mpanda, Ms Delia S. Veraguas Segura.

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Quelle: http://www.medizin-unwahrheiten.de/die_aids_luge.html Ein exzessiver Lebensstil liess das Phänomen AIDS entstehen Hätte die US- Seuchenbehörde CDC die Krankengeschichte von fünf jungen Männern im Jahre 1981 richtig eingeschätzt, wäre wohl niemals der riesige Stein ins Rollen geraten, dessen Ausmass schnell bis in die entlegendsten Regionen Afrikas zu spüren war. Als zwischen Okt

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Journal of Applied Biology & Biotechnology Vol. 1 (02), pp. 013-017, July- Aug, 2013 Available online at http://www.jabonline.in DOI: 10.7324/JABB.2013.1203 Gastroenteritis with Eschericha coli in pediatric hospital in N’Djamena-Chad Bessimbaye N1,5, Tidjani A2*, Moussa AM1,2, Brahim BO2, Mbanga D 1,2, Ndoutamia G3, Sangare L4, Barro N5, Traore AS5 1General Hospital of Nation

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JEFFERSON TOWNSHIP PUBLIC SCHOOLS AUTHORIZATION OF EMERGENCY TREATMENT (All Areas Must Be Completed) ________________________________________ is allergic to: ______________________ Allergic Reaction Risk Level: _____ Low _____ Moderate _____ High If you suspect that a food allergen has been ingested (or insect sting), immediately determine the symptoms and treat the

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VYDAC® Columns for USP and Pharmaceutical Analyses The VYDAC SELECTAPORE™ is recommended for USP analyses. The Penicillin V contributes stability and long column life. analysis. Variations in selectivity based onThe specially treated base silica minimizestailing for alkaline analytes, and the 300 Åpore size provides uniform surface accessfor large multi-ring molecules. Performance

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washingtonpost.com: Against Depression, a Sugar Pill Is Hard to Beat washingtonpost.com Against Depression, a Sugar Pill Is Hard to Beat Placebos Improve Mood, Change Brain Chemistry in Majority of Trials of Antidepressants By Shankar Vedantam Washington Post Staff Writer Tuesday, May 7, 2002; Page A01 After thousands of studies, hundreds of millions of prescriptions and tens of bill

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Cosmetic Laser Skin Resurfacing with the DOT laser You have scheduled a delicate cosmetic laser procedure. The following information is intended to assist you in preparing for your procedure. Below are the instructions you need to follow to prepare for your procedure. If you have any questions, please do not hesitate to call the office. • Your DOT laser procedure is scheduled on ______________

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CURRICULUM VITAE NAME John DATE OF BIRTH MARITAL STATUS CHILDREN UNIVERSITY St. George's Hospital Medical School, London, UK AWARDS 1960 Anna Selina Fernee Scholarship: St. George's Hospital Medical School. Medical Research Council Clinical Research Fellow, St. Thomas' Hospital. Wellcome Research Fellowship: MRC Tropical Metabolism Research Unit, University of t

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JK SCIENCE EDITORIAL Postmenopausal Obesity Sudhaa Sharma, Rupali Bakshi, Vishal. R. Tandon, Annil Mahajan The prevalence of obesity is increasing world wide Table-1 Health Benefits of Exercise/Weight Reduction (7-10) and is reaching epidemic proportions. Majority of adults• Fall of 10mm of Hg in systolic BP & diastolic BPare becoming increasingly overweight and one of the s

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Wolfe v McNeil-PPC, Inc. – A current application of the failure-to-warn doctrine. By Charles J. Crooks, Esquire, a member of Jackson Kelly PLLC For: Law360’s May 2011 Product Liability Guest Column N ew products are constantly being developed to meet modern needs and expectations. The law evolves to regulate the development, marketing and use of theseproducts. Tort law governs clai

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MEDICATION SAFETY This series brings you up-to-date information about medication safety issues and strategies to prevent medicationerrors. It draws on Australian incidents and US experience, including (with permission) material from ISMP MedicationSafety Alert! a bulletin published by the US Institute for Safe Medication Practices <www.ismp.org>. This series iscoordinated via the C

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M i n d & B o d y A n A l g e s i c s It doesn’t hurt to ask If you find the wide array of pain-relief options on the market bewildering, your pharmacist should have all the answers. Words: Julie Penfold Illustration: Toby Morison When you need pain relief Options:  “Analgesics such as  over-the-counter (OTC) remedy  options for headaches,” says  Per

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Jamal Mohamed College (Autonomous), Tiruchirappalli-20 RESUME (as on 31.07.2012) Department of Chemistry (Aided) 3. Designation 4. Date of birth 5. Address: Residential Phone No.: 0431- 2713664, Mobile : 9865560226 Official 6. Educational Qualification a. B.Sc. Chemistry 1985 b. M.Sc. Chemistry 1989 c. M.Phil. Chemistry 1997 d. Ph.D., Chemistry 2003 7. E

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Journal of Animal Science Volume 79, Number 5, May 2001 APPLIED ANIMAL SCIENCE Effect of group size on pig performance in a wean-to-finish production system. B. F. Wolter, M. Ellis, S. E. Curtis, N. R. Augspurger, D. N. Hamilton, E. N. Parr, and D. M. Webel .1067 Effect of weaning status and implant regimen on growth, performance, and carcass characteristics of steers. J. P. Sch

Pfizer breaks from merger mentality as others chase leads

Pfizer breaks from merger mentality as others chase leads It was less than two years ago that the its review of its portfolio during the second half blockbusters coming off patent, either.”pharmaceutical giant Pfizer made headlines of the year and is still determining the optimal Meanwhile, some pharmaceutical companies when it acquired the drugmaker Wyeth for mix of businesses that it c

Pii: s0304-4017(01)00565-9

Veterinary Parasitology 101 (2001) 405–414Molecular approaches to studying benzimidazoleJ.F. Humbert a , ∗, J. Cabaret b, L. Elard c, V. Leignel d, A. Silvestre ba INRA, Station d’Hydrobiologie Lacustre, BP 511, 74203 Thonon Cedex, France b INRA, Station de Pathologie Aviaire et de Parasitologie, 37380 Nouzilly, France c Laboratoire de Parasitologie Fondamentale et Fonctionnelle,

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CURRICULUM VITAE Kay M. Hood 1600 Nottingham Knoll Drive Jacksonville, FL, 32225 904-256-7626 Florida RN License 3381472, Licensed as an ARNP, 2000-present Georgia RN License R64505, Licensed as an ARNP 1981-present NCC Certified Women’s Health Nurse Practitioner 1982-present NCC Certified Reproductive Endocrinology/Infertility 1989-present EDUCATION University of Flo

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SECURITY DETAILS Complying with de European Committee 91/155/EEC, last modification 2001/58/EC (07/27/01) and R.D. 255/2003. 1. IDENTIFICATION OF THE SUBSTANCE/PREPARATION AND OF THE COMPANY. VINFERMATON (SPECIAL COCKROACHES) P roduct Code: LABORATORIES VINFER S.A. POLIGONO IND’L CAMPOLLANO C/D Nº 2 TEL: 967 52 35 01 FAX. 967 24 29 14 +34 967 52 35 01

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Bases de Concurso Promocional “ANIVERSARIO JUMBO 2009” Primero: Organizador Del Concurso Cencosud Retail S.A. RUT: 81.201.000-k, con el objeto de beneficiar a los clientes de su sitio de comercio electrónico jumbo.cl, ha organizado una promoción denominada “ANIVERSARIO JUMBO 2009” . En ella podrán participar todos los clientes que realicen compras de las marcas adheridas

jornadaseducacion.unlu.edu.ar

VIII JORNADAS DE EDUCACIÓN EN PERCEPCIÓN REMOTA EN EL ÁMBITO DEL MERCOSUR 13 al 16 DE NOVIEMBRE DE 2011 PROGRAMA MIERCOLES 16 CONFERENCIA INVITADA CURSO INTERNACIONAL- DA ESPECIALIZAÇÃO AO MESTRADO PROFISIONAL: CONSTRUINDO CAPACIDADES NA AMÉRICA LATINA 9:00 – 9:30 Dra. Tania María Sausen (Instituto Nacional de Pesquisas Espaciais y Centro Regional Sul de Pesquisas

Microsoft word - sir_john_froissart.rtf

MEMOIRS OF THE LIFE OF SIR JOHN FROISSART Sir John Froissart’s Chronicles of England, France and The Adjoining Countries, form the latter part of the reign of EdwardII to the coronation of Henry IV To Which is Added Some Account of the Manuscript of His Chronicle in the Elizabethian Library at Breslau and A Complete Index. Newly translated from the best French Editions, with Variations and Addit

jointcentreforbioethics.ca

Human Values as Normative Propositions Behind Design of Pharmacotherapy Processes A conversational workshop jointly sponsored by: Leslie Dan Faculty of Pharmacy, Joint Centre for Bioethics, Knowledge Media Design Institute Monday, March 12, 4:00-6:00 pm Leslie Dan Building, 144 College St, rm B150 to be followed by reception in Leslie Dan Bldg Atrium 6:00-7:00 pm co

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United Malays National Organization: UMNOCouncil of Southeast Asia and the Pacific: RISEAPReligious Affairs Department/Jabatan Ugama IslamCouncil of Muslim Religion/Majlis Agama IslamMalaysian National Council for Islamic AffairsNagata, Judith 1984 ; Chandara Muzaffar 1987 ; Hussin Mutalib 1990 ; ZainahHussin Mutalib 1990 , pp. 128 152; Khoo 1995 , pp. 159 197Hussin Mutalib 1990 , pp. 128 1

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Today’s Date: _____________________________________ Patient Name:________________________________________________________________Birthdate:____________________________________ 1. Have you been under the care of a medical doctor during the past 2 years?. Yes If yes, for what?____________________________________________________________________________________________________ Physician’s Name?

Microsoft word - sulaiman al-zuhair.doc

Inhibitory effect of dates-extract on α -Amylase and α -glucosidase enzymes relevant to non-insulin dependent diabetes mellitus Sulaiman Al-Zuhair*, Ali Dowa idar and Hassan Kamal Received: 4 April 2010 / Received in revised form: 9 June 2010, Accepted: 9 June 2010, Published online: 7 July 2010 Abstract α-Amylase and α-glucosidase are key enzymes involved in available

Microsoft word - online gold rush.doc

Online Gold Rush Retail has long been the key touch point between goods manufacturers and end consumers. So it is no surprise that the sector has been vibrant and innovative, bringing such inventions to the market as: layaways; self service shopping; concept stores, in-store bakeries, factory outlet centres, loyalty cards; pop-up shops, airport retailing - even scuba diving in retail malls.

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Review Article Psychological characteristics associated with tobacco smoking behavior* Regina de Cássia Rondina1, Ricardo Gorayeb2, Clóvis Botelho3 Abstract This article is a literature review of the psychological aspects of smoking behavior, highlighting personality characteristics of the smoker as an obstacle to smoking cessation. It describes the relationship between smoking behav

Microsoft word - pharmacy - terminology.doc

Pharmacy Terminology Pharmacy Technicians Acknowledgments Winnipeg Technical College and the Department of Labour and Immigration of Manitoba wish to express sincere appreciation to all contributors. Special acknowledgments are extended to the following individuals: Recognition of Prior Learning Coordinator, Winnipeg Technical College Grace Leduc, Curriculum Develop

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Gesundheitsdienst Regionalarztstelle Merkblatt für Beschäftigte (Stand: 02.10/GvL/GB) Höhenkrankheit Wenn Reisen ins Hochgebirge vernünftig vorbereitet werden, besteht für Gesunde nur ein geringes Risiko. Sogar gute Erholung ist möglich. Touristen und Reisende im Hochgebirge gehen aber selbst aus Unwissenheit unnötige Risiken ein. Hierzu zählen besonders: Berg

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EFFECT OF FERMENTED CHUB MACKEREL EXTRACT ON LIPID METABOLISM OF DIABETIC RATS U. Santoso1, S. Ishikawa2 and K. Tanaka2 1 Faculty of Agriculture, Bengkulu University, Bengkulu - Indonesia. 2Division of Bioresources and Bioproduction, Graduate School of Agriculture, Hokkaido University, Sapporo 060-0809 - Japan Corresponding E-mail: santosoburgo60@yahoo.com Received January 26, 2

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Psychoactive Medication Information for Patients (Pharmacotherapy - Psychopharmacology) Medication Class Chemical Name Trade Name Side Effects & Possible Uses Selective Serotonin Reuptake Inhibitors practitioner and/or dispensing pharmacist to discuss the range of possible or common Zoloft, Concorz, Sertra, Setrona, Eleva, Xydep, Sertracor S

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INTRODUCTION Indian Research Output on Malaria: A Bibliometric Study using Scopus Data Base Malaria is a major public health problem in India, accounting for sizeable morbidity, mortality and economic loss. Around 1.5 million confirmed cases are reported annually by the National Vector Borne Disease Control Programme (NVBDCP), of which Department of Library and Information science

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http://www.emergenzafestival.de/showreviews.php?ID=157Letzte Vorrunde in Marburg, Köln und in Frankfurt!Die Bands zeigten vielfältige Stilrichtungen in allen 3StädtenWritten 21.3.2011 by Sabrina Lüftner Die Tour startet dieses Wochenende im KFZ Marburg. In diesem Jahr war ich dort schon einmal mitEmergenza. Bunt gemischtes Genre und 9 Bands, davon nur wenigeaus Marburg dir

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JOB NO. 13-351 C ITY & BO R O U G H O F JU N EA U A LA SK A 'S C A PITA L C ITY CAPITAL CITY FIRE & RESCUE - FIRE March 12, 2013 J O B A N N O U N C E M E N T FIREFIGHTER-EMT I $24.78 Hourly Approximately April 22, 2013 thru September 30, 2013 NOTE: HOURLY RATE BASED ON A 40 HOUR WORK WEEK (3 VACANCIES) Are you looking for summer employment working in the em

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Implementation of Electronic Dividend Payment (“eDividend”) We are pleased to inform you of the provision of eDividend to shareholders, by Jerasia Capital Berhad (“ the Company ”). The eDividend refers to the payment of cash dividends by the Company directly into the shareholders’ bank accounts. One of the main objectives of implementing eDividend is to promote greater effici

Five horsemen of the apocalypse

Ares WAILS on him. Cipro wraps his hands around Ares’s Ares grabs a hammer. A BLOW to Cipro’s head. He crumples. Ares TOSSES Cipro through another wall. Daylight FLOODS the closet. Ares JUMPS through the gaping hole. Ares SAILS through the air. LANDS on the sidewalk. Concrete moans, fractures. Fire hydrants BREAK. Water GUSHES. Ares glances up at the sky. Undulating black clouds move in.

Microsoft word - mental illness.doc

Jenni Sells Psychological Anthropology Professor Snodgrass September 21, 2009 Mental illness, for all intents and purposes, is a highly subjective category of disease that can change drastically depending upon who is viewing the illness, and through which lens they see the patient. It’s not a simple task to diagnose and treat any mood disorder or mental illness through a narrow frame with wh

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APRIL 08, 2013 Nifty Outlook NIFTY Critical Level The Indian markets are expected to open down on weak global cues.The NSE Nifty after the initial volatility it may try to hold above its first support at 5532.Below this,the benchmark could find the major support at 5512.The Critical level on the upside is at 5568 and above this,it might move towards the resistance at 5588

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Evidence Reports of Kampo Treatment 2010 Task Force for Evidence Reports / Clinical Practice Guideline Special Committee for EBM, the Japan Society for Oriental Medicine Reference Ohnishi M, Hitoshi K, Katoh M, et al. Effect of a Kampo preparation, Byakkokaninjinto, on the pharmacokinetics of ciprofloxacin and tetracycline. Biological & Pharmaceutical Bulletin 2009; 32: 1080–4. CE

432 489.494

The Benzophenanthridine Alkaloid Fagaronine InducesErythroleukemic Cell Differentiation by Geneof GATA-1 gene by 3.2-fold. A mutation within the GATA-1 bind-ing sites strongly decreased the promoter activation induced byFagaronine, a benzophenanthridine alkaloid from Fagara zan-FAG. Taken together, our results represent a demonstration thatthoxyloides Lam. (Rutaceae), has been tested on the e

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CURRICULUM VITAE Dr. Nancy Budambula, Ph.D. MSc. BSc. Contact: New Science Complex, 2nd floor e-mail: nbudambula@fsc.jkuat.ac.ke Current position: Senior Lecturer / Chairperson Botany Department Previous Cccupations: Programme Officer, Project Officer and Environment Consultant. Recognition : Honoured and recognized in Who’s Who in Science and Engineering in the 10th Anni

Amparo_-_canevaro_y_otro_-_matrimonio_gay_-_36410_-_final

Poder Judicial de la Ciudad Autónoma de Buenos Aires “CANEVARO, MARTÍN Y OTRO C/ GCBA S/AMPARO (ART. 14 CCABA)”, Expte. Nº EXP 36410/0 ///dad Autónoma de Buenos Aires, 19 de marzo de 2010.- VISTOS: para dictar sentencia en la presente causa iniciada por los actores MARTÍN CANEVARO y CARLOS HUMBERTO ÁLVAREZ NAZARENO, de cuyas constancias; RESULTA: 1. Que MARTÍN

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ZAPAIN Capsules Abbreviated Prescribing Information (Consult SPC for Full Prescribing Information) COMPOSITION: Each capsule contains paracetamol 500mg and codeine phosphate 30mg PRESENTATION: In pack sizes of 56, 100 or 112 capsules. INDICATIONS: For relief of severe pain. DOSAGE & ADMINISTRATION: Method of administration: Oral. Adults: One or two capsules every four h

Aa.index.458-484.4.13

Activated carbon, for hangovers, 246–47Allergies. See also Food allergiesAcustimulation wrist bands, for nausea, 131ADD. See Attention deficit disorderAntifungal herbs, for athlete’s foot, 56Anti-inflammatory foods, for carpal tunnel Antioxidants. See Vitamin A; Vitamin C; www.jerrybaker.com Bedstraw, for bloating, 99Bee stings. See Insect bites and stingsBenzoyl peroxide, f

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IN THE GRAND COURT OF THE CAYMAN ISLANDS BEFORE: The Honourable Madam Justice Levers Counsel of Plaintiff: Ms. Margeta Facey-Clarke of Facey-Clarke & Counsel for the Defendant: Mr. H. Delroy Murray of Associated In this case KW, the Plaintiff sues the Defendant LW in negligence. It is alleged that on 31 October 2000, the Plaintiff was employed by the Defendant to carry out an assigned jo

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ORIGINAL RESEARCH Bupropion and Restless Legs Syndrome:A Randomized Controlled Trial Max Bayard, MD, Beth Bailey, PhD, Deep Acharya, MD, Farhana Ambreen, MD,Sonia Duggal, MD, Taran Kaur, MD, Zia Ur Rahman, MD, Kim Roller, MD,and Fred Tudiver, MD Introduction: Restless legs syndrome (RLS) is a common neurological disorder affecting 10% of the population. Most antidepressants exacerbate sy

We welcome you as our patient

Name: ______________________________ Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you have not done some of these activities recently, try to think how you would react. Use the following scale to choose the most appropriate number rating for each situation. 0 = would NEVER doze 1 = SLIGHT

Naehrstoffraeuber

Aspirin kann die Ausscheidung von Vitamin C verdreifa-Mehr denn je zuvor werden ständig irgendwelche Medikamente geschluckt. Was die meisten aber nicht wissen: viele dieser Medikamente - ob vomArzt verschrieben oder ohne Rezept gekauft - entziehen genauso viel wiesie geben, jedenfalls unter dem Gesichtspunkt der Ernährung. Allzu oftstoppen die Medikamente entweder die Aufnahme von Nährstoffen

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Judy J. Davis, M.D., F.A.A.P. 7405 N. Fresno Street, Fresno, CA 93720 (559) 438-8400 FAX (559) 438-1174 INFORMED CONSENT FOR TREATMENT OF HEPATITIS C WITH INTERFERON AND RIBAVIRIN Your medical provider has recommended treatment with Interferon and ribavirin for hepatitis C infection. These medications have been approved by the FDA for the treatment of hepatitis C. The goal of treat

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JORNAL DO ESTADO Tatuagem na Alma Mistérios do PIB, Idéias para Pauta mismo diante da evolução mas a matéria foi um bom a indústria? O do investimento bruto. esforço inicial para pôr o Desta vez, disse um deles, o assunto em perspectiva. A crescimento da economia Folha de S.Paulo, também nomia de serviços”, como é mais firme do que nou-as do mundo rico, ou os tros

jas-online.org

Consent Form for Exercise Treadmill Testing Authorization I authorize Edward J. Lind M.D. to perform an exercise treadmill test (stress test). Possibility of other procedures As a result of having this test, I understand there is a possibility I may need other urgent procedures that were unanticipated. I consent to the performance of any additional procedures determined to be in my b

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SUMMARY OF PRODUCT CHARACTERISTICS NAME OF THE MEDICINAL PRODUCT Januvia 100 mg film-coated tablets 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each tablet contains sitagliptin phosphate monohydrate, equivalent to 100 mg sitagliptin. For a full list of excipients, see section 6.1. 3. PHARMACEUTICAL Film-coated tablet (tablet) Round, beige film-coated tablet with “27

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Contents Solvent extraction is a technique which has been highly developed within many nationalnuclear energy programs because of its suitability as a selective separation process for fissionproducts, actinides, and other radioactive substances. The technique is briefly described inseveral sections of this book (§§ 5.5.3, 9.2.6, 9.4.3, 15.7.4, 16.3.3, 21.7, and especially in21.6 on the Purex

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Title: Counterstrain manipulation in the treatment of Restless Legs Syndrome: a pilot single-blind randomised controlled trial; the CARL Trial. Peters, T 1, MacDonald, R* 1, Leach, CMJ 2 1 London College of Osteopathic Medicine, Marylebone, London, UK 2 Clinical Research Centre for Health Professions, University of Brighton, UK. CORRESPONDENCE : R S MacDonald, LCOM, 8, Boston Place, NW1

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Evening Seminar I Clinical Application of Dexmedetomidine in Neuroanesthesiology EI-01 Neuroprotective Role Given by Dexmedetomidine May Improve Clinical Neurological (Medical Department, Asia-Pacific Region, Hospira Japan Co., Ltd, Japan) EI-02 Dexmedetomidine for Patients with Acute Subarachnoid Hemorrhage (Department of Neuroanesthesia, Kohnan Hospital, Japan) EI-03 Effects of Perio

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2014 JCC of Mid-Westchester Camps Staff Medical Form Return to Camp Office by May 30, 2014 Name __________________________________________________________________ Birth date _______________ Age at camp __________ Home address ________________________________________________________________________________________________________ Custodial parent/guardian __________________________

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