Penn Aqua Preserve Permit Application

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Name *

First

Last

Address

City, State, Zip

Contact Person's Email *

Cell Phone Number *

Club Affiliation

NSS Member *

NSS Number

MAKC Member *

MAKC Number

Proposed Trip Date *

Estimated Time of Arrival *

Call Out Time *

Emergency Contact Name *

First

Last

Contact Person's Phone *

Contact Person's Email *

Emergency Contact Other Information

Number of Participants (Minimum 4, Maximum 15) *

Date

Time

How many in the group have been to Penn Aqua before? *

Equipment (for each participant) *

How many vehicles expected?

Any fees involved with this trip? *

Will any diving occur on this trip?

Has the trip leader read and understood the access guidelines, and agreed to complly?

Name

Mid-Atlantic Karst Conservancy, Inc. • 137 East Campbell Street • Blairsville • PA • 15717 • info@karst.org •