Registration 1/6/16, 10:47 AM Ritt Kellogg Memorial Fund Registration Registration No. V1RR-WY7D2 Submitted Jan 4, 2016 3:45pm by Michael Hasson Registration Sep 1, 2015- Ritt Kellogg Memorial Fund Waiting for Aug 31 RKMF Expedition Grant 2015/2016/Group Application Approval This is the group application for a RKMF Expedition Grant. In this application you will be asked to provide important details concerning your expedition. Participant Michael Hasson Colorado College Student Planned Graduation: Summer Break 2019 CC ID Number: 152336
[email protected] [email protected] [email protected] (415) 250-1799 (Cell/Text) Date of Birth: Nov 7, 1995 Emergency Contacts Nancy Hasson (Mother) (415) 613-1437 (415) 331-1437 (Alternate) Medical History Allergies (food, drug, materials, insects, etc.) Peanuts (Epi-Pen) 1. Anaphylactic shock can occur. Treatment is to give Zyrtec and administer epi-pen if need be. No serious reactions in last 16 years. Additional Questions Medications No current medications Special Dietary Needs I try to avoid dairy https://apps.ideal-logic.com/worker/report/28CD7-DX6C/H9P3-DFPWP_cf931841a25d69cf/pf830d77f/ac89a81f24c1b/registration.html Page 1 of 8 Registration 1/6/16, 10:47 AM Physician No physician Last Doctor's Visit Date: Aug 10, 2015 Results: General check up - all ok. Insurance Covered by Insurance Yes Insurance Details Carrier: Cigna Name of Insured: Kirke Hasson Relationship to Michael: father Group Number: 3209584 Policy Number: U0913198403 Date Effective: Jan 2015 Phone Number: (800) 244-6224 Consent Ritt Kellogg Memorial Fund Consent Form (Jul 15, 2013) Michael Hasson Recorded (Jan 4, 2016, MAH) USE THIS WAIVER (Nov 5, 2013) Michael Hasson Recorded (Jan 4, 2016, MAH) I.