Please complete the form below to register as a chaperone for the Headwaters Academy Iceland trip. Please note, there is a $500 additional fee for all adult participants. We will confirm participation for all requests as soon as possible once student enrollment numbers are known and reviewed by the trip leaders at Headwaters Academy.

Name (Full legal name as it appears on a legal document to be used for flying):

First Middle Last

Gender (as identified for the airline):

Email Address:

Phone Number:

Date of Birth:

Mailing Address:

Name of Student you are Traveling with:

Emergency Contact Name:

Emergency Contact Relationship To Participant:

Emergency Contact Phone Number:

T-shirt size (Adult mens and womens sizes- XS - XXL):

Which trip would you like to chaperone?

Trip A (boys): May 8 - 15

Trip B (girls): May 16 - 22

Which trip would your student like to attend?

Trip A (boys): May 8 - 15

Trip B (girls): May 16 - 22