The Mountain Institute
Summer Adventures 2005 - Application

Mail of fax completed application
and deposit to:
The Mountain Institute
100 Campus Drive, Elkins, WV 26241
E-mail: learning@mountain.org 		Tel: 1-800-874-3050
Fax: 1-304-567-2666
Web: www.mountain.org

 


Student's Name _________________________________________ Nickname (if any) _______________________________

Address _______________________________________________________________________________________________

City _______________________________________________ State ________________ Zip _________________________

Phone ________________________________________ E-mail ________________________________________________

Age _______ Date of Birth ____________________ Height _______________ Weight ____________ M _______ F ________

Current Grade ________________________ School __________________________________________________________

Name of Father/Guardian _______________________________________________________________________________

Daytime Phone ___________________________ Evening Phone (if different from student's) ___________________________

Name of Mother/ Guardian _______________________________________________________________________________

Daytime Phone ___________________________ Evening Phone (if different from student's) ___________________________

Where did you hear about us? ____________________________________________________________________________

Course (s) you are applying for:
___ Astronomy Camp (July 31 - Aug. 6) cost $725.00   
___ Mountain Bike West Virginia (June 12 - 25) cost $1100.00
___ Youth Ecology I (June 12 - 16) cost $440.00
___ Youth Ecology I (July 10 - 14) cost $440.00
___ Youth Ecology II (June 19 - June 25) cost $635.00		   ___ Climb West Virginia (July 10 - 23) cost $1275.00
  ___ Potomac River Odyssey (June 26 - July 9) cost $1325.00
  ___ Cave West Virginia (June 26 - July 2) cost $690.00
  ___ West Virginia Odyssey (July 17 - 23) cost $685.00
  ___ Adventure Odyssey (July 3 - 9) cost $730.00
Payment Options (Credit cards are accepted for deposits only)
___ Deposit ($150.00; applies to program cost)  
___ Amount Paid Check (payable to The Mountain Institute)  

 ___ Tuition (payment in full required for late applications)
 ___ Visa             ___ MasterCard

Card # _________________________________________________________________ Expiration Date _______________

Cardholders Signature__________________________________________________________ Date__________________
Student Agreement
I have read all materials outlining the summer program of my choice and understand the nature of the program and it's activities. I have also read the Details included in the application and agree to abide by these terms. I agree to approach my adventure experience willing to cooperate and grow.

Applicant's Signature ___________________________________________________________ Date____________________

Parent/Guardian Agreement
I have read, understand, accept and agree to all the program policies and terms of agreement as set forth in the Details on the back of this application. I understand that The Mountain Institute does everything in its power to provide my child/ward with a safe experience. I further understand and feel properly informed about the risks and dangers inherent in the activities provided. I agree to release The Mountain Institute, it's agents, and guide services it contracts with , for any and all liability and responsibility for any loss/damage to property or personal injury incurred by my child/ward while participating in one of it's programs.

Parent/Guardian Signature ________________________________________________________ Date ___________________