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Print and KEEP Information Sheet
If you are unable to print from the website please contact us and we will send you an application.
Coastal Discoveries
55 Hay Street
Newbury, MA 01951
Tel. 978-462-8859
Fax. 978-499-7735
2010 Application........ $435.00 per wk.
Name:___________________________________M/F____Parent/Guardian_______________________________
City/State/Town__________________________________________________________________
E-Mail_____________________________________HomePhone: _____________________AGE_______
Emergency telephone #__________________________________________
Birth date:________________________Must be 9 or older - Swimming Ability__________________________
Enclosed is deposit of $_____________or please provide credit card inf.. (Mastercard or Visa)
Credit card #______________________________________Expiration date: (MM/YY)______________
Name on card______________________________________________________
Billing address for card______________________________________________
Amount to put on credit card $____________. And my choice of the following week/weeks.......
| June 21-25 |
|
July 26-30 Teens only - NO AVAILABLE SPACE |
| June 28-July 2 |
|
August 2-6 1 SPACE LEFT |
| July 5-9 Teens only (see notation below) |
|
August 9-13 |
| July 12-16 9 SPACES LEFT |
|
August 16-20 |
| July 19-23 3 SPACES LEFT |
|
August 23-27 |
Teens may attend any week or the teen only weeks.
Mass. State Safe Boating Course (must be 12 or older). Check if already completed_______
I give permission to enroll my child who is 12 years old or older in the Mass. State Safe Boating Course. Taught aboard the boat, my child will learn navigation, boat handling, and how to be a safe, responsible boater. Successful completion of this class with a passing score will result in a Mass. State Safe Boating Certificate issued by the Mass. Environmental Police. I understand this course is incorporated into the weeks activities, will not detract from any group activities and is offered at no additional fee. X____________________________________
Photo release: I give permission for Coastal Discoveries to use photographs or video of my child taken during camp for their advertising or promotional use either via their website or for print advertising. X______________________________________.
T-Shirt order: I would like my child to receive a Coastal Discoveries T-Shirt, adult sizes,
SM____MED____LG_____. Please add $15.00 per shirt with your deposit payment.
Medical release and consent: I authorize any attending physician to administer emergency care to my child in the event of injury while participating in Coastal Discoveries. I understand that my child is participating in this program under his/her own risk. My child has permission to participate in camp activities held aboard the Erica Lee II and on the program’s additional boats which may include dories and a small skiff. I will not hold Coastal Discoveries responsible should injury or loss occur. X______________________________________.
List any allergies or medications that need to be taken during program hours or any special needs your child may have. ___________________________________________
___________________________________________________________________________
