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Please enable JavaScript in your browser to complete this form.
-
Step
1
of 3
Personal Profile
Course Dates
*
Father's Name
*
First
Last
Child's Name
*
First
Last
Mailing Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Cell Phone
*
Work Phone
*
Email
*
Birthdate (Dad)
*
Age at time of Course (Dad)
*
Birthdate (Child)
*
Age at time of Course (Child)
*
How did you find out about Summit Adventure and our Adventures in Fatherhood Course?
*
Next
Emergency Contact Info
Please fill out the section below (must be above 18).
Name
*
First
Last
Relationship
*
Phone
*
Doctor's Name
*
First
Last
Doctor's Phone
*
Next
Health Insurance Information
Summit carries limited accident and illness insurance. Please answer the following questions in detail for our insurance records.
Do the participants have insurance?
*
Yes
No
Insurance Company
*
Policy Number
Group Number
Address of Insurer
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is your child's insurance different from the above?
*
yes
no
Insurance Company
Policy Number
Group Number
Website
Submit