Note: If you have any problems submitting this application, please call our office at 888-833-1907 or 919-833-1907, or send an email to info@gobroadreach.com.

Step 1 of 6

* Indicates a required field.

Program Selection

*First Trip Choice

Trip Name

*First Trip Choice Code

Second Trip Choice

Trip Name

Second Trip Choice Code

Participant's Information

*Participant's Name

First		Last

Nickname

*Participant's Email

Instant Messenger IDs

Yahoo		AOL		MSN

*Gender

Male

Female

*Birthday

mm/dd/yyyy

*Weight

lbs

*Height

*Shoe Size

*T-Shirt Size

*Scuba Experience

*Chinese Experience

*French Experience

*Spanish Experience

*Participant lives

Please Specify if Other

*Current Grade

*School Name

*School Type

Is there any history of asthma or respiratory problems?*

Yes

Please contact our office at 888-833-1907 if your teen has a history of asthma, respiratory problems or any other medical conditions that may preclude their participation on one of our programs.