2021-2022 Sail Nauticus Academy Application
Thank you for your interest in the Sail Nauticus Academy! This application is for use by Sail Nauticus Staff only; information obtained via this application will not be shared with any other party.
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Email *
Please summit after completing this form. Contact us at sail.nauticus@gmail.com or 757-823-4242 for any questions
Part 1: Must be completed by a parent/guardian
Please complete the following forms in their entirety. Incomplete applications will not be considered.
1. Student Information:
Name: Last, First, Middle Initial *
Address: Number, Street Name, City, State, Zip *
Home Phone:
Date of Birth: *
MM
/
DD
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Grade entering Sept. 2021 *
Required
Gender *
Race: *
School Attending in 2021-2022: *
Student ID #: *
2. Parent/Guardian Information:
Name and Relationship to student (i.e. mother, father, aunt, uncle, etc.) *
Phone: *
Email: *
Preferred Method of Contact *
Approved to Pick-up? *
Additional Parent/Guardian Name and Relationship:
Additional Parent/Guardian Phone:
3. Additional Parent/Guardian Email:
Additional Parent/Guardian Preferred Method of Contact:
Clear selection
Approved for Pick-up?
Clear selection
Additional Emergency Contact Information:
Contact Name and Relationship (not parent or guardian): *
Contact Cell Phone: *
Approved for Pick-up? *
Please list anyone else who may pick up your student from Sail Nauticus:
(individuals will be asked for identification upon picking up your child)
4. Household Information
This section helps us determine specific demographics necessary for grant and funding purposes. This information is confidential and will not be shared outside of Sail Nauticus staff.
Would you describe your household as a “single-parent home”? *
Household Size (Total number of persons who live in your home, including the student): *
Does your child qualify for free or reduced lunch? *
5. Extracurricular Activities
Please list all extracurricular activities your student participates in during the school year, and the weekly time commitment: *
6. Health Information
Student's physician and phone number:
Please list any allergies, intolerance to food, medication, or other substances AND actions to take in an emergency situation: *
7. Parent/Guardian Expectations and Agreement
By signing below, I understand that if my child is accepted into the 2021-2022 Sail Nauticus Academy Program, my child and I (or an adult representative of my choice) MUST attend the Academy Orientation that will occur before the program begins. We will let you know a date once your student is accepted. Sail Nauticus will work with families who are unable to attend due to extenuating circumstances.
Parent/Guardian Signature *
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