Welcome

Adventures in the Environment
Student Information Sheet
 

 

STUDENT’S NAME_________________________________________________

 

AGE __________     GENDER   _______       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:

________________________________________________________________

 

 

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