Sea MD Journey Sign Up Form

I’m ready to go and all set to journey with Sea MD! I’ve verified that: This form will be received before the Journey signup deadline passes. I understand that Sea MD encourages me to scan/email this form to hold my spot as mail can take 3 to 7 days to be received.

I meet the “Criteria to Journey” found at www.SeaMD.org/signup-and-release-forms

If I need 1:1 staffing, I understand that I will need to provide this 1:1 staff

If I use a wheelchair, I will verify that my wheelchair and I can be accommodated on the journey.

S‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍ea MD Participant First name:‍‍‍

Sea MD Participant Last‍‍‍ name:

‍‍‍Birthdate: MM/DD/YYYY

Email:‍‍‍

Phone number:

Gender

Male

Female

City

State/Province

Country

How did you become aware of Sea MD?

Select Your Journey: type the name of the Sea MD Journey that you are signing up for:

Travel Insurance (Optional): travel insurance is not included in the Sea MD Journey cost and is not sold by Sea MD Inc. You can learn more about this type of insurance on our website at www.SeaMD.org

I want to pre-pay by purchasing Sea MD Journey Vouchers for a trip to be selected later.

Yes

Payment Information (see www.SeaMD.org/payment-details for Payment Schedule information.)

Deposit Included

Partial Payment Included

Full Payment Included

Apply from Journey Vouchers already purchased

Payment Type (please select preferred payment method. Sea MD will send a payment link for the Journey Deposit to the payee upon receiving the Participant Application.)

Visa, Mastercard

AMEX, Diner's Club

Certified or Personal Check

Pre-Purchased Sea MD Journey Vouchers

I understand that my application will not be approved prior to submitting my Participant Application and Participant Agreement & Release Form.

Additional Staffing Needs: 1:1 Personal Care Provider is required. (Additional fees required if Sea MD provides 1:1 Personal Care Provider. Sea MD Personal Care Providers assist in a 2:1 ratio - two Participants per Sea MD Personal Care Provider.)

Name of 1:1 Personal Care Provider to accompany Participant. (Some additional fees will be required such as 3rd Party Activity and Equipment rental fees for the Participant-provided Personal Care Provider.)

I, the above identified Sea MD Journey Participant, have reviewed the above registry information and verify that all the above information is true.

Criteria for Journey

1 : 1 Personal Care Criteria

Participant Application

Pre-Journey Documents