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ATLANTIC CHALLENGE USA

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SLOYD AND BOATS EXPEDITION
Thursday July 7 - Sunday July 10, 2022

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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. *

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: *

Please list any dietary restrictions or needs: *

Do you use an asthma inhaler? *

Yes No

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

What is your height and weight? *

What do you hope to gain from this experience? *

Payment information. Please select your sliding scale tuition rate based on your total annual household income(s)? *

Annual income up to $29,000 - Tuition: $240 $30,000 - $49,000 - Tuition: $300 $50,000 - $99,000 - Tuition: $400 $100, 000 - $184,000 - Tuition: $500 $185,000 or more - Tuition: $560

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

Do you use an epinephrine injector? *

Yes No

Have you received the Covid - 19 vaccine? *

Yes, fully vaccinated Not vaccinated

Are there any physical or medical conditions that will effect your ability to row or sail or participate fully? *

Are you already a Venturer Scout? We are insured through the Sea Scouts. *

Yes Not yet I don't know

How did you find out about Atlantic Challenge USA? *

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

Pay online Mail in a check: Make out to: Atlantic Challenge USA, and mail to: AC USA c/o Arista Holden PO Box 481 Belfast, ME 04915 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. We'll let you know how to proceed in getting onto our Sea Scouts roster. Do you have any questions at this time? *

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About
Join Us
The Boats
Our Instructors
Shop
Contact

SLOYD AND BOATS EXPEDITIONThursday July 7 - Sunday July 10, 2022

SLOYD AND BOATS EXPEDITION
Thursday July 7 - Sunday July 10, 2022