August Sign Up

August Penobscot Bay Expedition
Sunday August 20- Saturday August 26, 2023

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Name *

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Last

Email *

Address *

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City

State

Zip Code

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Your Pronouns *

She/Her He/Him They/Them Other pronouns not listed

Phone Number *

Date of Birth (Month/Day/Year) *

Emergency Contact *

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Last

Emergency Contact Relationship To You *

Emergency Contact Email *

Emergency Contact Phone Number *

Health Insurance Provider and Policy Number *

Please describe how you treat or care for your emotional or physical health care needs: *

Do you use an epinephrine injector? *

Yes No

Do you use an asthma inhaler? *

Yes No

Did you receive the COVID-19 vaccine? *

Yes No

What is your height and weight? *

Do you have any dietary restrictions? *

Are there any physical or medical conditions that will effect your ability to row, sail, and/or participate fully? *

How did you learn about Atlantic Challenge USA? *

What do you hope to gain from this experience? *

$100 is due at this time to hold your place in the programs. Please select your payment method: *

Pay online Send check: please make checks payable to "Atlantic Challenge USA" and mail to Mary Evans, 20 Star Ave, Riverside, RI 02915 Waive $100 deposit

Payment information. Please select your sliding scale tuition rate based on your annual household income(s). *

Annual income up to $29,000 - Tuition: $600 $30,000 - 49,000 - Tuition: $750 $50,000 - 99,000 - Tuition: $1,000 $100,000 - 184,000 - Tuition $1250 $185,000 or more - Tuition $1400 Will submit financial aid form

Thank you! We'll be in touch shortly to ask you any follow up questions, and to let you know the status of your acceptance into this program. There will be an additional $25 fee for insurance, which covers you in any of our programs or activities for one year. We'll let you know soon how to proceed with that. Do you have any questions at this time? *

August Penobscot Bay Expedition Sunday August 20- Saturday August 26, 2023

August Penobscot Bay Expedition
Sunday August 20- Saturday August 26, 2023