GENERAL QUESTIONNAIRE – ONE CHILD PER FORM
1) CHILD’S NAME AND DATE OF BIRTH
Surname………………………………………………….
Christian Name……………………………………………
Date of birth…………./………………./………………….
2) CHILD’S PARTICULARS Tick boxes for Yes or No Baptized in the Catholic Church?
Is familiar with the Traditional Latin Mass?
Is he receiving Catechism lessons from a Priest, Brother, or Sister?
Number of sisters…………………… Number of brothers…………………. Year level at school for 2014………………….
3) DETAILS OF PARENT/GUARDIAN
Relationship…………………………………………………………
Name……………………………………………………………….
Address.…………………………………………………………….
………………………………………………………………………
Contact Phone Number………………………….………………….
Email address……………………………………………………….
4) PAYMENT
Please enclose a cheque or cash for full payment: $180 ($140 for the 2nd child, 100 for the third,…). Cheques
are payable to the Society of St Pius X.
MEDICAL QUESTIONNAIRE – ONE CHILD PER FORM
5) MEDICAL INFORMATION Tick boxes for Yes or No Is allergic to penicillin or other forms of medication (specify below)
Suffers from asthma or other respiratory disorder
Is on regular medication (specify below)
Has a special dietary requirement (specify below)
His tetanus immunization will be current for January 2014
Year of the last tetanus booster: One number per square
Specified Problems (if more information is needed please attach an additional sheet) ……………………………………………………………………………………………………………
If there are any further details that would be useful for us to know, concerning: temperament of the child
(positive or negative), background, or any other. (All information will be confidential)
……………………………………………………………………………………………………………
6) PERMISSION FORM I,……………………………………give my permission for……………………………………………to attend
Saint Michael’s Boys’ Camp held at Mr. Bruce Kiifus’ Farm, 1291 Kopikopico Road, Pahiatua from 2nd January 2014 to 11th January 2014.
1. I give permission to the Director of the camp to send the child back to his parents/guardian before
the end of the camp if necessary (a reimbursement of $5 a day for those days missed will be made). I understand that transport to and from the venue is my responsibility in all cases.
2. I have read and approved the special conditions of the camp as outlined on the information sheet. 3. I give permission to the Director of the camp to render the necessary medical attention to my
4. I declare that any medical expenses are my financial responsibility.
5. My intention is that my child/charge will attend the whole camp from beginning to end, unless an
6. I understand that unforeseen accidents and injuries can and do occur even when precaution is taken
to avoid such events. Therefore I agree fully not to hold the Society of Saint Pius X or any of the
camp supervisors accountable for any type of reimbursement or compensation for injury or death that may occur.
Date…………………………………………. Signature………………………………………….
Phase III trials in oncologySetting standards of care?Survival data from phase III trials can be very misleading because patients arenot offered the best follow-up therapy argue Siegfried Seeber and Ada Braun in CancerWorld’s new Forum section. Emma Mason canvassed clinical trial leaders,and presents their responses in the Debate section that follows. For many years, oncologists enrolled p
Perinatal Outcome Following Third Trimester Exposure to Paroxetine Adriana Moldovan Costei, MD; Eran Kozer, MD; Tommy Ho, MD, FRCPC;Shinya Ito, MD; Gideon Koren, MD, FRCPC Background: Paroxetine hydrochloride is commonly women using paroxetine during the first or second tri-used for maternal depression, panic disorder, and obses-mester and 27 women using nonteratogenic drugs weresive-co
GENERAL QUESTIONNAIRE – ONE CHILD PER FORM
1) CHILD’S NAME AND DATE OF BIRTH 
MEDICAL QUESTIONNAIRE – ONE CHILD PER FORM