Vermilion Sea Institute · ADITO Non- Payment Registration 2024

Contact Information

Name

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First Name

Last Name

Preferred pronouns

Date of Birth

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(mm/dd/yyyy)

Email

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Verify Email

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Phone

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Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Dietary Committment

*

To have the appropriate quantities and reduce food waste, please take this opportunity to let us know which items you'll never eat.

No Fish

No Chicken

No Pork

No Beef

No Dairy

No Eggs

No Gluten

Other (add detail below)

No Dietary Restrictions

Dietary Restrictions

Please describe, in detail, any dietary restrictions not represented above. Please include the severity of the dietary sensitivity.

Allergy/Medical Information

*

Please describe any medical conditions or medications for this participant. Please Note that Vermilion Sea Institute (VSI) requests this information to assist staff in the management of courses and in the emergency response of medical conditions that any participant or observer may have. This information will remain protected and confidential. By requesting this information, VSI does not imply that we have the expertise to assess your physical condition or your ability to participate in this course. This determination of ability must be made by you, the participant, in concert with your physician.

Name of Emergency Contact (Not traveling with you)

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First Name

Last Name

Relation of Emergency Contact

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Phone Number for Emergency Contact

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Email for Emergency Contact

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Verify Email

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Passport Number

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Passport Issue Date

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(mm/dd/yyyy)

Passport Expiration Date

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(mm/dd/yyyy)

Would you like to receive the Vermilion Sea Institute Newsletter via email?

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Select "Yes" to receive updates about our work and invitations to upcoming events.