503.217.4469 info@rewildportland.com PO Box 31083, Portland OR 97231

Winter Break Camp Single Day – Dec 20th Registration

Winter Break Camp Single Day - Dec 20th 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 (must not be 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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