GSTA Summer Adventure Application 2021

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APPLICATION FOR SCUBA 301; 12-18 JUNE 2021

This application will not be complete until GSTA has received the $200 deposit. The deposit will be returned to you after your teen has attended the adventure, however if your teen does not attend the deposit will help GSTA cover the expenses incurred. Deposits can be mailed to Gold Star Teen Adventures, 2504 Raeford Road Suite 200, Fayetteville, NC 28305 or submitted via PayPal or Credit Card. You also have the opportunity to pay the deposit before you submit this application.

Gold Star Teen Adventure Policy: If a teen withdraws from an adventure, after the deposit has been paid, the teen will not be able to participate in future GSTA events. Along with taking a slot from another teen, many expenses are paid in advance and those expenses are not able to be recouped.
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Participant''s Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Date
Month
Day
Year
4
Gender* This field is required.
Male
Female
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Age at the time of adventure* This field is required.
14
15
16
17
18
19
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Grade* This field is required.
8th
9th
10th
11th
12th
freshman college
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Participant's Phone Number* This field is required.
Area Code
Phone Number
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Participant's Email * This field is required.
example@example.com
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Parent's or Emergency Contact's Name* This field is required.
First Name
Last Name
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Parent's or Emergency Contact's Email * This field is required.
example@example.com
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Parent's or Emergency Contact's Phone Number* This field is required.
Area Code
Phone Number
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Airport Traveling from:* This field is required.
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What level of dive certification does your teen have? Only if you are applying for a scuba adventure.
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Spouse's Name* This field is required.
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Spouse's Date of Death* This field is required.
Date
Month
Day
Year
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Spouse's Occupation* This field is required.
Military - Air Force
Military - Navy
Military - Marines
Military - Army
Military - Coast Guard
Law Enforcement
Fire/Rescue
U.S. Intelligence Agency
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Relationship of Fallen Hero to teen* This field is required.
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Please list any allergies or medical diagnosis (if yes, please explain)* This field is required.
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List any emotional, physical or medical needs our staff should be aware of? * This field is required.
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How did you hear about GSTA?* This field is required.
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Shoe Size?* This field is required.
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Shirt Size?* This field is required.
Small
Medium
Large
X-Large
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I grant permission to Gold Star Teen Adventures INC., its representatives, partnering foundations, vendors and staff/mentors to use any photographs of myself or of my property. I authorize Gold Star Teen Adventures INC., its assigness and transferees permission to use and publish the same in print and /or electronically.* This field is required.
Yes
No
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My teen has permission to be administered topical ointment for cuts and for minor injuries by GSTA staff, if necessary.* This field is required.
Yes
No
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My teen has permission to be administered over the counter medication (i.e. but not limited to Tylenol, Motrin) for headaches, nausea, and minor injuries by the GSTA staff, if necessary.* This field is required.
Yes
No
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CONFIRMATION

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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ADVENTURE DEPOSIT

You can submit your adventure deposit here. Please remember this application is not complete until the adventure deposit has been received. If you have any questions feel free to call Jessica at (910) 987-6314.

Credit Card, PayPal or mail to Gold Star Teen Adventures, 2504 Raeford Road Suite 200, Fayetteville, NC 28305.
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Signature
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