Class Enrollment Date:

 

Last Name of Student:                                     First Name of Student:

 

Date of Birth:               Age of Student:                                    Current Grade Level:

 

Group Affiliation:

 

Contact (Referred By):

 

Please List Medical Conditions or Allergies:

 

 

Last Name of Guardian:                                   First Name of Guardian:

 

Name of Spouse:

 

Address:

 

Home Phone:                           Cell Phone:

 

Work Phone:                            Work Ext:                     Fax Number:

 

Email:

 

In Case of Emergency Contact:

 

Emergency Contact Number:

 

I hereby grant permission to my minor charge,                                                                      , [Please print student’s Name] to attend the National Marine Institute’s Marine Science Program. The program consists of 12 two hour classroom sessions supplemented by field trips. Details will be provided the first week of class. All students are responsible for their own transportation, to and from, the school and the field trips. All expenses other than lunch and spending money on the trips are included and offered FREE to the students. I, [Print name of guardian]                                                           , acknowledge that some activities do carry inherent risks and understand that the National Marine Institute and the instructors will make every effort to ensure the safety and well being of said minor. Having read and understood the above stated facts, I,                                                   [Print name of guardian], release the National Marine Institute and its instructors, from and against, any liability.

 

Signature of Legal Guardian:                                                              Date