Costa Rica 2024
Before filling out this form, download and read our Participation Agreement at https://tinyurl.com/crossroadsagreement.   You will need to refer to it on this form.
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Enter Trip Date *
Student Information
First Name *
Last Name *
Full Name *
Exactly as it appears on your passport
Passport # *
Exactly as it appears on your passport
Passport Expiration Date *
MM
/
DD
/
YYYY
Gender *
Birthdate *
MM
/
DD
/
YYYY
Current Grade Level *
Street Address *
City *
State *
Zip Code *
Student Cell *
Include Area Code
Home Phone *
Include Area Code
Student Email *
Student Health Information
Medical Issues/Food Allergies *
Do you have any medical conditions or food considerations/allergies of which Crossroads' staff should be aware during our trip?
If you answered yes, please describe.
Please note if you are vegan or vegetarian here.
Medical Insurance Provider *
Policy # *
Physician Name *
Physician Phone *
Include Area Code
Parent/Guardian I Information
First Name *
Last Name *
Cell Phone *
Include Area Code
Email *
Parent/Guardian 2 Information
Please skip this section if there is only one parent or guardian.
First Name
Last Name
Cell Phone
Include Area Code
Email
Additional Information
Payment Method *
Participation Agreement *
We, the student applicant and at least one parent, have downloaded and agree with the Participation Agreement.
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