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Lagoon Island Family Adventure Request

Lagoon Island Family Adventure Request

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Lagoon Island Family Adventure Payment

Lagoon Island Family Adventure Payment

$150.00

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STEAM Immersion Program June 8, 2021

STEAM Immersion Program June 8, 2021

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STEAM Immersion Program June 15, 2021

STEAM Immersion Program June 15, 2021

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STEAM Immersion Program June 29, 2021

STEAM Immersion Program June 29, 2021

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Lagoon Island Family Adventure Request

Enjoy PRIVATE outdoor fun with the whole family!

Private Excursion

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First and Last Name*

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E-mail address*

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Phone Number*

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ex. (xxx) xxx-xxxx

Date of Excursion Request*

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Time*

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How many hours?

1st Choice Activity

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2nd Choice Activity

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3rd Choice Activity

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Total number of people in your party (adults and children included)*

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What ages are your children?*

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Is there anything else you'd like us to know about your family?*

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Lagoon Island Family Adventure Payment

Enjoy PRIVATE outdoor fun with the whole family!

Private Excursion - $150.00

Payment Day:

Payment Day:

Make my first payment today

First and Last Name*

This field is required.

E-mail address*

We need a valid email.

Phone Number*

This field is required.

ex. (xxx) xxx-xxxx

Date of Excursion Request*

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Time*

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How many hours?

1st Choice Activity

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2nd Choice Activity

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3rd Choice Activity

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Total number of people in your party (adults and children included)*

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Is there anything else you'd like us to know about your family?*

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Click Here For Indemnification and Hold Harmless Statement

I've read and agree to the terms and conditions of the indemnification and hold harmless statement*

Qty

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STEAM Immersion Program June 8, 2021

FREE for students in Indian River County! June 8, 9, 10, 2021 9am to 1pm.

ELC Member ELC Non-member

Payment Day:

Payment Day:

Make my first payment today

Student's first name*

This field is required.

Student's last name*

This field is required.

Student's birth date*

This field is required.

mm/dd/yyyy

Which Indian River County school does the student currently attend?*

This field is required.

Does the student qualify for free or reduced lunch?*

This field is required.

Student health history*

This field is required.

List Your Child's Allergies, Dietary Restrictions, Medications, Past Medical Treatments, Immunizations, Current Conditions, Activity Restrictions, and/or Behavioral Issues. If none please type 'none'

How well can your student swim?*

This field is required.

How well can your student canoe?*

This field is required.

Parent first name*

This field is required.

Parent last name*

This field is required.

Street address*

This field is required.

City*

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State*

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Zipcode*

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Primary Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

Alternate Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

Emergency Contact First and Last Name (Other than Parent Listed Above)*

This field is required.

Emergency Contact Relationship to Student*

This field is required.

Emergency Contact Primary Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

Emergency Contact Alternate Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

All adults authorized to pick up student*

This field is required.

Full Names Separated With a Comma

Email Address*

We need a valid email.

Click Here For Indemnification and Hold Harmless Statement

I've read and agree to the terms and conditions of the indemnification and hold harmless statement*

Click Here For Behavior Policy

I've read and agree to the Behavior Policy*

How did you hear about ELC STEAM Immersion Program?*

Newspaper

Website

Facebook

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Twitter

Email

Friend/Family

Other*

*If Other please indicate

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Payment

STEAM Immersion Program June 15, 2021

FREE for students in Indian River County! June 15, 16, 17, 2021 9am to 1pm.

ELC Member ELC Non-member

Payment Day:

Payment Day:

Make my first payment today

Student's first name*

This field is required.

Student's last name*

This field is required.

Student's birth date*

This field is required.

mm/dd/yyyy

Which Indian River County school does the student currently attend?*

This field is required.

Does the student qualify for free or reduced lunch?*

This field is required.

Student health history*

This field is required.

List Your Child's Allergies, Dietary Restrictions, Medications, Past Medical Treatments, Immunizations, Current Conditions, Activity Restrictions, and/or Behavioral Issues. If none please type 'none'

How well can your student swim?*

This field is required.

How well can your student canoe?*

This field is required.

Parent first name*

This field is required.

Parent last name*

This field is required.

Street address*

This field is required.

City*

This field is required.

State*

This field is required.

Zipcode*

This field is required.

Primary Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

Alternate Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

Emergency Contact First and Last Name (Other than Parent Listed Above)*

This field is required.

Emergency Contact Relationship to Student*

This field is required.

Emergency Contact Primary Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

Emergency Contact Alternate Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

All adults authorized to pick up student*

This field is required.

Full Names Separated With a Comma

Email Address*

We need a valid email.

Click Here For Indemnification and Hold Harmless Statement

I've read and agree to the terms and conditions of the indemnification and hold harmless statement*

Click Here For Behavior Policy

I've read and agree to the Behavior Policy*

How did you hear about ELC STEAM Immersion Program?*

Newspaper

Website

Facebook

Instagram

Twitter

Email

Friend/Family

Other*

*If Other please indicate

This field is required.

Keep Browsing

Payment

STEAM Immersion Program June 29, 2021

FREE for students in Indian River County! June 29, 30 and July 1, 2021 - 9am to 1pm.

ELC Member ELC Non-member

Payment Day:

Payment Day:

Make my first payment today

Student's first name*

This field is required.

Student's last name*

This field is required.

Student's birth date*

This field is required.

mm/dd/yyyy

Which Indian River County school does the student currently attend?*

This field is required.

Does the student qualify for free or reduced lunch?*

This field is required.

Student health history*

This field is required.

List Your Child's Allergies, Dietary Restrictions, Medications, Past Medical Treatments, Immunizations, Current Conditions, Activity Restrictions, and/or Behavioral Issues. If none please type 'none'

How well can your student swim?*

This field is required.

How well can your student canoe?*

This field is required.

Parent first name*

This field is required.

Parent last name*

This field is required.

Street address*

This field is required.

City*

This field is required.

State*

This field is required.

Zipcode*

This field is required.

Primary Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

Alternate Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

Emergency Contact First and Last Name (Other than Parent Listed Above)*

This field is required.

Emergency Contact Relationship to Student*

This field is required.

Emergency Contact Primary Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

Emergency Contact Alternate Phone Number*

This field is required.

Please use xxx-xxx-xxxx format

All adults authorized to pick up student*

This field is required.

Full Names Separated With a Comma

Email Address*

We need a valid email.

Click Here For Indemnification and Hold Harmless Statement

I've read and agree to the terms and conditions of the indemnification and hold harmless statement*

Click Here For Behavior Policy

I've read and agree to the Behavior Policy*

How did you hear about ELC STEAM Immersion Program?*

Newspaper

Website

Facebook

Instagram

Twitter

Email

Friend/Family

Other*

*If Other please indicate

This field is required.

Keep Browsing

Payment

255 Live Oak Drive, Vero Beach, Florida 32963

T: 772-589-5050
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E: info@DiscoverELC.org

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