Sand & Mud Camp (N/NE Portland) Registration

Student's Full Name:*

Student's Nick Name:

Parent or Gaurdian's Name*

Parent or Gaurdian #2 Name

Parent or Gaurdian #1 E-mail Address

Enter Email Confirm Email

Parent or Gaurdian #2 E-mail Address

Enter Email Confirm Email

Parent/Gaurdian #1 Phone

Parent/Gaurdian #2 Phone

Address*

Street Address Address Line 2 City State ZIP Code

Student's Date of Birth*

Student's Age*

Known Medical Conditions (i.e. allergies, medications, ADD, etc.):*

Emergency Contact Name (OTHER THAN PARENT)*

Relationship to Student*

Emergency Phone #*

List names of people authorized to pick up your child:*

How did you hear about us?*

What is your child's experience in nature?*

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