Participant Name
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First Name
Last Name
Participant Date of Birth
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MM
DD
YYYY
Her School and Current Grade
*
What is your relation to the child?
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If "Other" please explain
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
###
####
Email
Please describe your child's prior experience in the outdoors and/or engaging in physical activity.
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Have you ever participated in The Wild Way in the past? If so, which course?
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Why would your child like to participate in this course?
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Do you know anyone else enrolled in or applying to participate in this course? If so, who?
What is your race/ethnicity?
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Primary household language
*
Please disclose any medical conditions that may impact your child's safety or ability to participate. (Write "None" if none apply.)
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Will your child require any medication to be administered during her participation in the program? If so, please describe the medication, dosage, and administration. (Write "None" if none apply.)
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Does your child have any environmental and/or food allergies? Please describe the allergies, their severity, and your child's reaction. (Write "None" if none apply.)
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Does your child require a special diet or have any food intolerances? (Write "None" if none apply.)
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The cost of this event is $30 per child. Financial hardship should never be a barrier to enjoying the outdoors. The Wild Way provides low-cost services on a sliding scale fee. To support our program and ensure that we can continue to offer services, we ask that families who are financially-able make a contribution for their child to participate.
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Please indicate what you are able to pay. After you submit this form, you will be redirected to a secure page for payment.
How did you find out about The Wild Way?
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