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ATLANTIC CHALLENGE USA
About
2024 Contest
Join Us
The Boats
Testimonials
2023 Summer Expeditions
Community Rows in Belfast, ME
Our Instructors
Merch
Contact
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JULY COMMUNITY WEEK
SUNDAY July 16 - SATURDAY July 22, 2023
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Indicates required field
Name
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First
Last
Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Your Pronouns
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She/Her
He/Him
They/Them
Other pronouns not listed
Phone Number
*
Date of Birth (Month/Day/Year)
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Emergency Contact
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First
Last
Emergency Contact Relationship To You
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Emergency Contact Email
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Health Insurance Provider
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Emergency Contact Phone Number
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Health Insurance Policy Number
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Health History: Are you currently being treated for or have you been treated for any of the following? Please check all that apply. We can accommodate many needs. This information will help us know how best to support you.
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Diabetes
Do you use an insulin pump?
Hypertension (high blood pressure)
Adult or congenital heart disease / heart attack / chest pain / heart murmur / coronary artery disease
Any heart surgery or procedure
Any sudden heart related death of a family member before age 50
Stroke / TIA
Asthma / reactive airway disease
Lung / respiratory disease
COPD
Ears/ eyes / nose / sinus problems
Muscular / Skeletal conditions / muscle or bone issues
Head injury / concussion / TBI
Neurological / behavioral disorders
Blood disorders / sickle cell disease
Fainting spells and dizziness
Kidney disease
Seizures and epilepsy
Abdominal / stomach / digestive problems
Thyroid disease
Skin issues
Obstructive sleep apnea / sleep disorders
Psychiatric / psychological or emotional difficulties
Anxiety
ADHD
Please list any medical conditions you have and any medications you are taking:
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Please list any dietary restrictions or needs:
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Do you use an asthma inhaler?
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Yes
No
Please list all allergies and reactions you have to food, plants, medications, and insect stings or bites:
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What is your height and weight?
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What do you hope to gain from this experience?
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Payment information. Please select your sliding scale tuition rate based on your total annual household income(s)?
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Annual income up to $29,000 - Tuition: $600
$30,000 - $49,000 - Tuition: $750
$50,000 - $99,000 - Tuition: $1000
$100, 000 - $184,000 - Tuition: $1250
$185,000 or more - Tuition: $1400
Will Submit Financial Aid Form
Please describe how you treat or care for your physical or emotional health care needs:
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Do you use an epinephrine injector?
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Yes
No
Have you received the Covid - 19 vaccine?
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Yes
No
Are there any physical or medical conditions that will effect your ability to row or sail or participate fully?
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How did you find out about Atlantic Challenge USA?
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$100 is due at this time to hold your place in the program. Please select your payment method:
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Pay online
Mail in a check: Make out to: Atlantic Challenge USA, and mail to: AC USA c/o Mary Evans 20 Star Ave Riverside, RI 02915
Waive deposit fee
Thank you! We'll be in touch shortly to ask you any questions, and to let you know the status of your acceptance into this program. There will be an additional $25 fee for insurance, which is good for a year of any AC USA activities and programs. We'll let you know how to proceed with that soon. Do you have any questions at this time?
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Submit
About
2024 Contest
Join Us
The Boats
Testimonials
2023 Summer Expeditions
Community Rows in Belfast, ME
Our Instructors
Merch
Contact
Subscribe