New Treks Summer Intensive 2021 Registration Form
Fill out the form carefully for registration
Youth's Name (Nombre del Participante)
*
Last Name (Ultimo Nombre)
First Name (Primer Nombre)
Birth Date (Fecha de Nacimiento)
*
January
February
March
April
May
June
July
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December
Month
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Day
2021
2020
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Entering Grade
*
Gender (Género)
*
Please Select
Male (Hombre)
Female (Mujer)
N/A
Address (Dirección)
*
Street Address (dirección de casa)
Street Address Line 2
City (Ciudad)
State / Province (Estado/Provincia)
Postal / Zip Code (Código Postal)
Name of Insurance Provider (Nombre del Proveedor de Seguros)
Policy Number (Número de póliza)
Primary Care Physician (Médico de Atención Primaria)
Address and Contact Information (Dirección y Información del Contacto)
Hospital of Choice (Hospital de Elección)
List Any Medication Allergies (Lista de Alergias a Medicamentos)
Any Known Allergies (Alergias conocidas)
List Any Dietary Restrictions (Restricciones Dietarias)
List Any Medical Conditions we need to be Aware of and Treatment (Enumere las Afecciones Médicas que Debemos Conocer y el Tratamiento)
Parent/Guardian Name (Nombre del Padre/Guardián)
*
Last Name (Ultimo Nombre)
First Name (Primer Nombre)
Address (Dirección)
*
Street Address (dirección de casa)
Street Address Line 2
City (Ciudad)
State / Province (Estado/Provincia)
Postal / Zip Code (Código Postal)
Phone Number (Número de Teléfono)
*
Please enter a valid phone number. (Por Favor Ingrese un Número de Teléfono Válido)
Email
*
example@example.com
Secondary Contact Name (Nombre de Contacto Secundario)
*
Last Name (Ultimo Nombre)
First Name (Primer Nombre)
Address (Dirección)
*
Street Address (dirección de casa)
Street Address Line 2
City (Ciudad)
State / Province (Estado/Provincia)
Postal / Zip Code (Código Postal)
Phone Number (Número de Teléfono)
*
Please enter a valid phone number. (Por Favor Ingrese un Número de Teléfono Válido)
Email
*
example@example.com
Additional Emergency Contact (Contacto de Emergencia Adicional)
*
Last Name (Ultimo Nombre)
First Name (Primer Nombre)
Phone Number (Número de Teléfono)
*
Please enter a valid phone number. (Por Favor Ingrese un Número de Teléfono Válido)
List Any Additional Authorized Contacts or Pickup Persons
List Any Unauthorized Pickup Persons
*
N/A is acceptable
*Optional* Additional Demographic Information (select all that apply) (*Opcional* Información Demográfica Adicional)
Native Indian or Alaska Native/Nativo India o Nativo de Alaska
Asian/Asiático
Black or African American/Negro o Afroamericano
Native Hawaiian or Pacific Islander/Nativo Hawaiano o Isleño del Pacifico
Latino/Hispana
White/Blanco
Other/Otro
*Optional* Does your Youth Qualify for Free or Reduced Lunch? (*Opcional* ¿Su Joven Califica para Almuerzo Gratis o Reducido?)
Yes/Si
No
Please provide documentation of Free and Reduced Lunch to qualify for the reduced price. (Por Favor Proporcionar Documentación para el Almuerzo Gratis o Reducido.)
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*Optional* Primary Language Spoken at Home (*Opcional* Idioma Principal Hablado en Casa)
Additional Comments (Commentos Addicionales)
Intensive Selection (Selection Intensivo)
Please select the activity and date you wish to register for. After registration is complete an email will be sent asking for the DEPOSIT to hold your reservation accompanied by the WAIVERS that need to be signed. If the intensive is full we will notify you and put you on a waiting list. All waivers will be sent to your email for signature and full payment will be required by May 14, 2020. ***If you selected that your youth receives Free and Reduced Lunch you will be sent the adjusted payment rate.***
My Products
*
Categories:
All
All
Rock Climbing Intensive
Paddling Intensive
Backpacking Intensive
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( X )
Rock Climbing Intensive
May 31 - June 4, 2021 Grades 6-8
$
Free
# of Youth
Entering Grade Level
6
7
8
Rock Climbing Intensive
June 21 - June 25, 2021 Grades 9-12
$
Free
# of Youth
Entering Grade Level
9
10
11
12
Rock Climbing Intensive
July 12 - July 16, 2021 Grades 6-8
$
Free
# of Youth
Entering Grade Level
6
7
8
Backpacking Intensive
June 7 - 11, 2021 Grades 9-12
$
Free
# of Youth
Entering Grade Level
9
10
11
12
Backpacking Intensive
June 28 - July 2, 2021 Grades 6-8
$
Free
# of Youth
Entering Grade Level
6
7
8
Backpacking Intensive
July 19 - July 23, 2021 Grades 4-5
$
Free
# of Youth
Entering Grade Level
4
5
Paddling Intensive
June 14 - 18, 2021 Grades 4-5
$
Free
# of Youth
Entering Grade Level
4
5
Paddling Intensive
July 5 - 9, 2021 Grades 9-12
$
Free
# of Youth
Entering Grade Level
9
10
11
12
Paddling Intensive
July 26 - 30, 2021 Grades 6-8
$
Free
# of Youth
Entering Grade Level
6
7
8
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