Participant Name
*
First Name
Last Name
Participant Date of Birth
*
MM
DD
YYYY
Her School and Current Grade
*
What is your relation to the child?
*
If "Other" please explain
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Please describe your child's prior experience in the outdoors and/or engaging in physical activity.
*
Have you ever participated in The Wild Way in the past? If so, which course?
*
Why would your child like to participate in this course?
*
Do you know anyone else enrolled in or applying to participate in this course? If so, who?
What is your race/ethnicity?
*
Primary household language
*
Please disclose any medical conditions that may impact your child's safety or ability to participate. (Write "None" if none apply.)
*
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.)
*
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.)
*
Does your child require a special diet or have any food intolerances? (Write "None" if none apply.)
*
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.
*
We have included suggested donation amounts appropriate for this activity or course. Please indicate the amount that you'd be able to contribute. (For families facing significant financial hardship, we provide fee waivers on a case-by-case basis.)
Once you are confirmed to be enrolled, we will follow-up with you for your donation.
How did you find out about The Wild Way?
*
