DolphinLab: Teen Basic

Application

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Directions: Please print this application single-sided. Please type or print clearly. Please update us of any changes in address or telephone numbers. This application must be accompanied by a deposit via check or money order for $300.00 (U.S. Currency). Please see last page if you would like to pay by credit card. Also, please include a fax number and/or email address accessible to your parent or guardian.

Name: Last First Middle

Current Street Address:

City/State/Postal Code:

Telephone No.: Parent/Guardian Work Home Parent/Guardian Cell Student Cell Parent/Guardian Fax

Parent/Guardian Email Address:

Student's Email Address:

Permanent Street Address/City/State/Postal Code & Phone Number:

Student's Birthdate: / Month / Day Year Age: Sex:

Student's Education: Grade Levels Completed:

Emergency Contact: Name/Relationship Home Telephone # & Cell #

Reservations Data: Refer to the online schedule for class dates. Indicate if you are interested in being put on standby should the class be full. Housing accommodations consist of a two-story dormitory with four bedrooms sleeping 4-6 people per room on bunk beds.

First Choice Class DatesStandby Second Choice Class Dates Standby

DO NOT USE this form if applying for: Teen Intermediate or Teen Marine Mammal Care & Basic Training. If wishing to apply for these courses, please contact the Education Department at 305/289-1121 x225.

It is essential that you describe, below, any dietary restrictions, health conditions or disabilities that might either warrant special consideration or possibly interfere with your ability to participate in any portion of the program. Advanced notice of any restrictions/conditions/disabilities allows us to better accommodate your needs.

Please note the following:

• The dormitory is accessed by stairs and is approximately a 150 yard walk from DRC.
• One may not participate in activities involving direct interaction with the dolphins if he/she has any respiratory infection, open sores or other outward signs of illness; or if any physical conditions exist that might place him/her at an increased risk.
• Women may not participate in activities involving direct interaction with the dolphins if they are pregnant

For each of the following, check the column that best describes you:

	Low or None	Fair	Good	Excellent	Comments
Swimming skills
Snorkeling skills
Health and fitness
Marine mammal knowledge
English language skills

Provide a brief answer to each of the following (use additional paper if necessary):

1. How did you originally hear about… (Please name your sources specifically.)

   Dolphin Research Center?	DolphinLab?
   friend/relative	friend/relative
   school/other organization	school/other organization
   book/article	book/article
   TV/radio program	TV/radio program
   lecture/presentation	lecture/presentation
   internet	internet
   other	other

2. Describe any previous activity or involvement with DRC (DRC visit, Dolphin Interactive program, Dolfriend, Adopt-a-Dolphin, donations, intern or volunteer). Include dates if known.

3. Describe any activity of involvement with other environmental, conservation or animal related organizations.

4. Describe your prior experience or exposure to dolphins or marine mammals in general.

5. What is your perception of dolphins?

6. What reasons do you accept as being valid for maintaining dolphins in a human care setting?

7. What are your personal goals and expectations in attending Basic DolphinLab? Please include any specific areas of interest.

Sign and date application in the space provided below. Return application to:
Dolphin Research Center
Attn: DolphinLab Reservations
58901 Overseas Highway
Grassy Key, FL 33050-6019

You must include a deposit check, cashier's check or money order for $300 (U.S. Currency) made payable to Dolphin Research Center. (Please see attached sheet if you prefer paying by credit card.) Payment may be made by credit card, personal check, money order, or cashier’s check in US dollars. If application is sent within 60 days of a course then full payment is due with the application. Any payments sent in within 21 days of the course must be by credit card, money order, or cashier's check.

Your enrollment will be confirmed in writing and the deposit will be applied toward your total tuition. The remaining balance is due 60 days prior to the class start date. If the balance is not received by the due date, reservations are subject to cancellation and the deposit becomes non-refundable.

Cancellation of a confirmed reservation must be made in writing. If a cancellation is received more than 60 days before the start of your class, your deposit minus a processing fee of $35 will be refunded to you. Cancellations made less than 60 days before the class are not eligible for a refund regardless of reason, including weather and medical emergencies. Please note that hurricane season extends from June to November, with the most active time frame being in September. Therefore, we recommend that you purchase trip insurance through your travel agent to cover the cost of DolphinLab and travel for such events.

Applicant Signature Date Parent/Guardian if under age 18 Date

* Dolphin Research Center would appreciate your help with connecting DolphinLab students. Please provide your signature below if you would like to grant DolphinLab staff the right to share your name, telephone number and email address with other DolphinLab students signed up for your class.

Applicant Signature Date Parent/Guardian if under age 18 Date

Payment Information

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Applicant's Name:
Dates of DolphinLab applying for:

Method of payment (check the method you are using):

Check, money order or cashier’s check enclosed. (If you are making your payment less than 21 days prior to the class, tuition must be submitted in the form of a money order or cashier's check.)

Charge to my Credit Card

For those charging deposits & tuition via credit card, please read the following:

Two payments will be processed on your card:

1. An initial deposit of $300.00 to secure the applicant's space in the class will be charged on your credit card. This fee will be applied to the entire tuition.
2. Upon confirmation of the class (when minimum enrollment has been reached) at 60 days before the class the final balance payment of $1200.00 will be charged on your credit card. Credit card payments are subject to credit approval.

If paying tuition via credit card, please supply the following information:

Credit Card #: ---

Expiration Date: / Month Year

Name as it appears on credit card:

I, , authorize the full tuition amount of to be charged on my credit card for the DolphinLab class I am enrolling in at Dolphin Research Center.

Signature of Card Holder: Date:

Billing address:
Street Address 1:
Street Address 2:
City:
State/Prov:
Zip/Postal Code: Country:

Dolphin Research Center, 58901 Overseas Highway, Grassy Key, FL 33050
(305) 289-1121, education@dolphins.org