Primary Applicant

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth

YYYY

Phone

(###)

###

####

Sailing Competency

None

Limited

Intermediate

Expert

Emergency Contact

Emergency Contact #1

First Name

Last Name

Relationship

Phone

(###)

###

####

Emergency Contact #2

First Name

Last Name

Relationship

Phone 2

(###)

###

####

Additional Information

Please briefly describe any sailing experience you have had:

What, if any, goals do you have for the trip?

What part of the trip are you most excited about about?

Are there any concerns you have for the trip? Are you uneasy about sailing, the ocean, swimming or this experience?

Do you or anyone joining you have any scuba diving experience?

Yes

Would you like to include diving as part of the trip?

Yes

Any additional information you wish to share?:

Individual Questionnaire