(Participant Only) in the space below, please tell us why you would like to be a part of the programs you've signed up for?
Emergency Contact (primary and alternate)
Please tell us about any medical issues we should be aware of.
Please list the participant's allergies if any.
Does the participant take any medications or history of substance abuse? If so, please list.
I give permission to Lake Champlain Maritime Museum staff and representatives to dispense over the counter medication (such as ibuprofen, aspirin, acetaminophen, antihistamines, Imodium and antacids) on an as needed basis?
Does the participant have any physical or emotional disabilities or history of substance abuse? If yes, please describe. A positive response to this question does not automatically disqualify you from participating and all information will remain confidential. Upon acceptance into any expedition program, we will require a physical and medical form to be filled out and signed by your doctor.
Upon acceptance into the program we require a physician
complete a physical then complete can sign a medical form.
After you submit this form, a member of our staff will contact you within 36 hours (excluding weekends) to complete the application process.