Blue Horizon Coastal Science Lab

Attendee Information

First Name

Last Name

Suffix

Preferred Name

Email Address

Birthdate

The minimum age for participants is 14 years old

Sex

Gender Identity

Personal Pronouns

Do you identify as Hispanic or Latino?

Indicate how you would identify (check all that apply):

Mailing Address

Country

Street

City

Region

Postal Code

Cell Phone

Home Phone

High School
Select your school from the list provided. Enter number '000000' if your school does not appear in the list.

Please enter the name of the high school you currently attend:

Anticipated Graduation Year

Current GPA:

Are you a first generation college attendee?

Yes

No

Are you currently interested in any major(s) at MMA (select all that apply)

Do you have any relatives or friends who are either MMA students or alumni?

No

Yes

Please list:

How did you hear about us?

Please list:

T-shirt size

Parent/Guardian Information

Relationship

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Suffix

Parent/Guardian 1 Email

Parent/Guardian 1 Phone

Do you wish to provide information for an additional parent/guardian?

No

Yes

Relationship

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Suffix

Parent/Guardian 2 Email

Parent/Guardian 2 Phone

Insurance Information

Insurance Company Name

Policy Holder's Name

Insurance Policy Number

Medical

Allergies

Yes

No

Please list known allergies:

Medications

Yes

No

Please list required prescription medications:

I understand that participants are required to submit a copy of their most recent physical. I am able to provide this prior to July 1.

Yes

Did your household receive any of the following? Please check all that apply:

Payment

Do you have a fee waiver?

Yes

No

Promo/Fee Waiver Code (codes are case sensitive)

100% Promo Code Discount Applied

Please enter a valid code

Blue Horizon Coastal Science Lab Cancellation Policy

The Blue Horizon Coastal Science Lab runs rain or shine unless inclement weather would prevent an activity from running. Massachusetts Maritime Academy and Blue Horizon Coastal Science Lab staff reserve the right to cancel or modify any activity during the program.

If the participant and/or family members/guardians cancel:

Anytime up to July 1, a full refund will be issued
Anytime after July 1 until the end of the program there will be no refund
- This will exclude any extenuating circumstances (i.e. death, serious illness, etc.)
- This includes any participant who is sent home early from violating the code of conduct

Written requests made for refunds will be considered by the Blue Horizon Program Director and the Dean of Enrollment. A refund will not be issued when a participant does not attend check in.

At least one phone number must be provided for the attendee

Signature

Amount Due
Transaction Fee	Dependent on selected payment type
Total	Dependent on selected payment type
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Amount Due

Transaction Fee

Dependent on selected payment type

Total

Dependent on selected payment type

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