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ATLANTIC CHALLENGE USA

About
Join Us
The Boats
Our Instructors
Merch
Contact

Chesapeake Bay Sailing Clinic
Wednesday July 5th - Wednesday July 12th

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Name *

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Email *

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Your Pronouns *

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Phone Number *

Birthday (Month/Day/Year) *

Emergency Contact *

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Last

Emergency Contact Email *

Health Insurance Provider *

Health Insurance Policy Number *

Do you have any physical or medical conditions that will effect your ability to participate in sailing in this program? *

No Yes.

Please describe: *

Please list any dietary restrictions and needs *

Health History: Do you currently have or have you ever had any of the following? Please check all that apply. *

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. Family history of heart disease or 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 Blood disorders/sickle cell disease Fainting spells and dizziness Kidney disease Seizures or epilepsy Abdominal/ stomach/ digestive problems Thyroid disease Skin issues Obstructive sleep apnea/ sleep disorders Psychiatric / psychological or emotional difficulties Anxiety ADHD

Please list any other medical conditions or pertinent medical history covered above *

Please describe how you treat or care for your physical or emotional health care needs: *

Please list all allergies and reactions you have to food, plants, medications, and / or insect bites and stings? *

Do you use an epinephrine injector? *

Yes No

Do you use an asthma inhaler? *

No Yes

Have you received the Covid-19 vaccine? *

Yes No

How did you hear about Atlantic Challenge USA? *

What do you hope to gain from this experience? *

The water temperature will be around 75 degrees. We will likely get in the water every day. Do you have any concerns or questions about getting in the water? We will bring lifejackets. *

Payment Information: Please select your sliding scale tuition rate based on your annual household income(s). Cost includes three meals a day plus snacks, instruction, transport to Maryland from Maine, and accommodations. *

Annual Income up to $29,000 - Tuition: $900 $30,000 - $50,000 - Tuition: $1125 $50,000 - $99,000 - Tuition: $1500 $100,000 - $184,000 - Tuition: $1875 $185,000 or more - Tuition: $2100 Will submit an application for financial aid

Emergency Contact Relationship To You *

Emergency Contact Phone Number *

Additional Emergency Contact Phone Number (and Name if different from above) *

Please describe any medical conditions you have and any medications you are taking. *

What is your height and weight? *

A deposit of $100 is due at this time to hold your place in the program. Please select your payment method: *

Pay online Pay by check. Make check out to: Atlantic Challenge USA and mail to: 20 Star Ave, Riverside, RI 02915 Waive $100 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 in this program, and how to proceed with getting on our insurance ($25/year additional fee). Do you have any questions at this time? *

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About
Join Us
The Boats
Our Instructors
Merch
Contact

Chesapeake Bay Sailing ClinicWednesday July 5th - Wednesday July 12th

Chesapeake Bay Sailing Clinic
Wednesday July 5th - Wednesday July 12th