Please complete the form below to register for the Headwaters Academy Iceland Trip. All submissions will be reviewed by the trip leaders at Headwaters Academy for final admission onto the trip.

Student's Name (Full legal name as it appears on the passport)

First Middle Last

Passport # (if you have it already):

Passport Expiration Date

Student's gender (As identified on passport)

Student Date of Birth

Student Email Address

Student Phone Number

Student Age At Time of Travel (May 1, 2025)

Mailing Address

Emergency Contact Name

Emergency Contact Relationship To Student

Emergency Contact Phone Number

Emergency Contact Email

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