All fields with an asterik are required.

Personal Information

*First Name

*Last Name

*Address

*City *State

*Zip Code

Day Phone

*Evening Phone

*E-mail Address

Would you like to participate in our monthly email update program? (Monthly in the summer only)
Yes No

How did you hear about us?
Please select one. . . Web Search Engine Brochure/ Business Card Referral - Friend Referral - Website Referral - Other Repeat Customer Other

Class/Trip Information

*Please specify class/trip Please select a class/trip. . . Private Full Day Private Half Day

*Height *Weight

Gender Male Female Age

Will you need a sea kayak and paddling equipment?
(kayak, paddle, PFD, spray skirt, whistle, paddle float, bilge pump are included in the cost)
Yes No

Will you need a wet suit (Included in the cost for the Rollling/Rescue Clinic)?
Yes No

Medical Information (Confidential)

In case of emergency notify:

Name

Relationship

Day Phone

Evening Phone

Insurance Company

Group Number

Policy Number

Do you have any allergies? (bee stings, food, medications, etc.)

Are you taking any medications either prescription or non-prescription?

Do you have any health conditions that I should be aware of? (back/joint problems, heart problems, diabetes, asthma, etc.)

This information is collected in order to ensure your safety during the course and in the unlikely event of an accident. Once the course is complete the information is destroyed (or returned to you at your request). If you have any concerns about a medical or physiological condition please contact me.