Student Application 2023
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Adventures in the Environment
Student Information Sheet

 
hosted by the Rotary Club of Cornwall Sunrise
 
STUDENT’S NAME_________________________________________________
 
AGE __________     SEX    F      M       GRADE  ___ SCHOOL _________________
 
STREET ADDRESS _________________________________________________
 
TOWN ________________________ PROV ___  POSTAL CODE ____________
 
TELEPHONE _____________ EMERGENCY PHONE NUMBER _______________
 
E-MAIL (please print clearly)  ________________________________________ 
 
HEALTH INSURANCE NUMBER _______________________________________
 
ALLERGIES/MEDICAL CONDITIONS/ FOOD RESTRICTIONS – or anything else we should know that would impact participation:
________________________________________________________________
 
T-shirt size:   Medium      Large                X Large
 
HOW ARE YOU GETTING TO AND FROM THE INSTITUTE?
________________________________________________________________
 
I understand the nature of the Adventures in the Environment program.  I understand that all activities involve certain elements of risk.  Accidents can occur without any fault on the part of the student, the host club or the facility where the activity is taking place.  I agree to abide by the rules of the host Rotary Club of Cornwall Sunrise and the Institute.

Student signature _________________________________date ___________
                                                            
Parent/guardian signature   _________________________ date ____________

Rotary contact – Katie Burke – brkcornwall@gmail.com