Mississippi Registration Form

A FEW DETAILS TO SMOOTH THE WAY

Thanks in advance for giving us a few more details. We promise to keep these safe and secure.

Full Name (as on your passport or official ID)

First Name

Last Name

How you like to be known

Email Address

Phone Number (inc international code if not UK)

Your home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Passport Number

Nationality

Date of birth

Date of Issue (ID/Passport)

Date of Expiry (ID/Passport)

Gender/Sex

Female

Male

Other

Emergency Contact

Your dietary requirements/ allergies

Kayak/Canoe/SUP experience (if any)

Can you swim?

Yes

No

Any medical issues?

What is your height?

What is your weight?

Have you paid your deposit yet?

Yes

No

As soon as you submit this form please send a head and shoulders photo of yourself to dave@davecornthwaite.com