Maryland Sign Up

Chesapeake Bay Sailing Clinic
Wednesday July 5th - Sunday July 9th

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Name *

First

Last

Email *

Phone Number *

Birthday (Month/Day/Year) *

Address *

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Line 2

City

State

Zip Code

Country

Your Pronouns *

She/Her He/Him They/Them Others not listed

Emergency Contact *

First

Last

Emergency Contact Email *

Emergency Contact Relationship To You *

Emergency Contact Phone Number *

Additional Emergency Contact Phone Number (and Name if different from above) *

Health Insurance Provider *

Health Insurance Policy Number *

What is your height and weight? *

Please describe any medical conditions you have and any medications you are taking. *

Do you have any physical or medical conditions that will effect your ability to participate in sailing in this program? *

No Yes.

Please describe: *

Please list any dietary restrictions and needs *

Please list any other medical conditions or pertinent medical history covered above *

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

Please list all allergies and reactions you have to food, plants, medications, and / or insect bites and stings? *

Do you use an epinephrine injector? *

Yes No

Do you use an asthma inhaler? *

No Yes

What is your sleeping preference? *

I'd prefer to sleep in a private bedroom I don't mind sharing a bedroom with one other I don't mind sleeping on a camp pad with up to two others

How did you hear about Atlantic Challenge USA? *

What do you hope to gain from this experience? *

The water temperature will be around 75 degrees. Do you have any concerns or questions about getting in the water? We ask that our participants have a basic swimming ability. We will bring lifejackets. *

Payment Information: Please select your sliding scale tuition rate based on your annual household income(s). Cost includes three meals a day plus snacks, instruction, transport to Maryland from Maine, and accommodations. *

Annual Income up to $29,000 - Tuition: $720 $30,000 - $50,000 - Tuition: $900 $50,000 - $99,000 - Tuition: $1200 $100,000 - $184,000 - Tuition: $1500 $185,000 or more - Tuition: $1680 Will submit an application for financial aid

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

Pay online Pay by check. Make check out to: Atlantic Challenge USA and mail to: 20 Star Ave, Riverside, RI 02915 Waive $100 deposit fee

Thank you! We'll be in touch shortly to ask you any questions, and to let you know the status of your acceptance in this program, and how to proceed with getting on our insurance ($25/year additional fee). Do you have any questions at this time? *

Chesapeake Bay Sailing ClinicWednesday July 5th - Sunday July 9th

Chesapeake Bay Sailing Clinic
Wednesday July 5th - Sunday July 9th