By filling out this form we will reserve a spot for your child while we wait for you to send the Official Application  and your payment.

* Required fields
Name *
E-mail Address *
M/F *	M F
Mailing Address:
City:
State:
Zip Code:
Home Phone: *
Emergency telephone #: *
Birth Date: "Must be 9 or older"
Swimming Ability
How many weeks? Note: Teens can attend any week or the "Teen Only" week.	1 2 3 4 5 6 7 8 9
	July 2-6 ADULT
	July 9-13 TEENS ONLY
	July 16-20 FOR AGES 10-12
	July 23-27 TEENS ONLY
	July 30-Aug 3 TEENS ONLY
	Aug 6-10 FOR AGES 10-12
	Aug 13-17 FOR AGES 10-12
	Aug 20-24 FOR AGES 10-12
Has your child completed the Mass. State Safe Boating Course? *	YES NO
Do you give your permission for your child to enroll in the Mass. State Safe Boating Course.	YES NO
Permission for Coastal Discoveries to use Photos, Video of your child or children.	YES NO
I would like my child to receive a Coastal Discoveries T-Shirt adult sizes: Please add $15 per shirt when sending your deposit.	SM MED LG
List any allergies or medications that need to be taken during program hours or any special needs your child may have.
Questions and Comments

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For 2012:  Send $50-$100 with the application.  You may then make 3 more payments 1-2 months apart.  The final payment of no more than $200 will be due on the first day of your child's week of camp.

When sending your reservation money please remember to include $15 for each TShirt.

Print and send the application with your payment please.

 Email

Coastal Discoveries 
55 Hay Street
Newbury, MA  01951
Tel. 978-462-8859  Fax. 978-499-7735

Captain Bob's Cell Phone 978-815-6160

Lee's Cell Phone  978-479-1632

Fishing Charters Newburyport

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