W.I.L.D. Registration

Complete and submit the form below to register for the Wilderness Institute. You will receive a confirmation email upon receipt and processing of your completed registration.

W.I.L.D. Event:

----------------------------------------YOUR INFORMATION ----------------------------------------

First Name:

Last Name:

Organization:

Street Address:

City:

State/Province:

Zip/Postal Code:

Work Phone:

Cell Phone:

Email:

Gender:

Unisex T-shirt Size:

----------------------------------------EMERGENCY CONTACT ----------------------------------------

Emergency Contact:

Relationship to You:

Contact Work Phone:

Contact Cell Phone:

Have you attended WILD before?:

If yes, when?:

----------------------------------------HEALTH INFORMATION ----------------------------------------

Do you have any medical conditions?:

If so, explain.:

Do you have any allergies?:

If so, explain.:

Are you taking any medications?:

If so, explain.:

Do you have any dietary restrictions?:

If so, explain.:

Do you carry any medical insurance?:

Medical Insurance Company:

Policy #:

----------------------------------------COLLEGE or GRADUATE CREDIT----------------------------------------

Are you enrolling for college or graduate credit?:

If so, from which school?:

If enrolling for credit, which course?:

----------------------------------------PAYMENT INFO----------------------------------------

Payment Amount:

Payment Method:

CC#:

Expiration Date:

CVV2:

How did you hear about WILD?:

By submitting this form, you agree to the following TERMS & CONDITIONS:

**Your $75 deposit is non-refundable and non-transferable and is necessary to reserve a space in any WILD. Please make checks payable to PILGRIMAGE.

We make every effort to provide you a quality trip. Our staff will give instructions before each trip and it is important that you listen and do as they say. You will assume the responsibility for many decisions affecting your safety during this trip. These activities can be physically demanding with inherent elements of risk and danger beyond our control. We do not assume liability for personal injury or deaths. You must sign a release form and go at your own risk. We offer trips requiring various degrees of fitness. We are not qualified to evaluate your fitness, so you must evaluate your fitness as appropriate for any given trip. If you are overweight or in poor physical condition, you should consult with you physician before the trip. Upon receipt of the WILD Registration Form and deposit, a packet will be sent including the following: WILD Cover Letter, Invoice Form, Participant Agreement & Release Form, Medical History Form, Learning Objectives Form, Personal Clothing & Equipment List, Directions to Base Camp and WILD Syllabus.

By submitting this form with a deposit, I understand that I am applying to be included in the Wilderness Institute for Leadership Development course to be held during the above-designated dates. I understand that Pilgrimage reserves the right to withhold my acceptance to the course, in which case my deposit will be refunded. I also understand that, if accepted, my deposit is non-refundable and non-transferable.

Required field