Participant Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Parent/Guardian *

First Name

Last Name

Phone *

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

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If Yes, what is the name and contact information of additional person responsible for participant transportation?

First Name

Last Name

Phone

(###)

###

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Pick-Up/Drop-off schedule and locations *

M, T, Th, F: 8:30 AM drop-off, 1:00 PM Pick-up at St. John's Episcopal Church, 48 Middle Street, Gloucester Wednesday - Adventure Sail Day!: 8:30 Drop-off, 1:00 PM Pick-up at the Maritime Museum, 23 Harbor Loop, Gloucester

Yes, I understand the Pick-Up/Drop-off schedule and locations

I understand that there is no tuition for my my 13-17 year old child to participate as a Mentor.

PERMISSION & RESPONSIBILITY *

I understand the nature of the varied activities planned for this program. I hold harmless teachers/directors from liability and claims arising out my child's participation. In the event of accident or illness, the directors have my permission to seek necessary emergency treatment if the guardian cannot be reached.

By checking this box I agree with the above statement