Gold Star Teen Adventures Wreck Trek 2017

June 25th - July 1st, 2017

To secure your application the GSTA waiver must be submitted and the $200 deposit received. The link for the waiver is at the end of this application.

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Teen must have Advanced Scuba Certification

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A $200 deposit is required to complete the application. The deposit will be returned to you after your teen has attended the adventure, however if your teen does not attend the deposit will help GSTA cover the expenses incurred. Deposits can be mailed to Gold Star Teen Adventures, 3350 Footbridge Lane, Ste 124, Fayetteville, NC 28306

Teen's First Name *

Teen's Last Name
(as it appears on travel documents) *

Parent's First Name *

Parent's Last Name *

Gender *

Birth Date * +

Age *

Grade *

Shirt Size *

Shoe Size *

Mailing Address *

City *

State *

Zip *

Teen's Phone #

Parent's Phone #

Teen's Email Address *

Parent's Email Address *

Spouse's Name *

Spouse's Branch of Service and
Military Occupation Special *

Spouse's Date of Death *

Relationship of Fallen Hero to teen *

Is your teen comfortable
talking about their loss or
do they avoid the topic? *

Closest INTERNATIONAL airport. * 🛈

Has your teen
ever flown alone? *

Does your teen have any allergies
or medical diagnosis (if so, please explain) *

What activities does your teen
participate in throughout the year? *

Does your teen have emotional, physical or
medical needs our staff should be aware of? *

Can we honor your Fallen Hero on our website's Tribute page? *

I grant permission to Gold Star Teen Adventures INC., its representatives, partnering foundations, vendors and staff/mentors to use any photographs of myself or of my property. I authorize Gold Star Teen Adventures INC., its assigness and transferees permission to use and publish the same in print and /or electronically. *

My teen has permission to be administered topical ointment for cuts and for minor injuries by GSTA staff, if necessary. *

My teen has permission to be administered over the counter medication (i.e. but not limited to Tylenol, Motrin) for headaches, nausea, and minor injuries by the GSTA staff, if necessary. *

GSTA Open Water Waiver - must be completed to finalize applicaition

Parent's Signature (or teen if over 18 years of age) *

clear

Date Signed * +