Adventures in the Environment
Student information sheet

Hosted by the Rotary Club of Cornwall Sunrise
(please print/write legibly)
Student’s name: ____________________________________
Age: ____   Sex: M  F      Grade:____    School _______________

Street Address:______________________________________________

Town: ____________________Prov/State ______Postal/Zip code______
Phone: (         ) __________  Emergency contact Number __________

E-mail: ___________________________________

Health Insurance number: _______________________

Allergies, medical conditions, food restrictions – or anything else we should know:
T-shirt size:     M           L            XL
Specific area(s) of interest in environmental science: ________________
How are you getting to and from Cornwall?_______________________
I understand the nature of the Adventure 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 Rotary club or the facility where the activity is taking place.  I also agree to abide by the rules of the host Rotary Club of Cornwall Sunrise and the host family.  I understand that I may not drive during my stay in Cornwall.
Student signature: ___________________________ date:___________________
Parent/guardian signature: _____________________ date: __________________
Name of the sponsoring Rotary Club _____________________________
Name of sponsoring club coordinator: _____________________________
Please return completed forms by August 31, 2020 to:
Katie Burke
435 York Street
Cornwall ON K6J 3Z6                 613-933-8353