Wilderness Institute Enrollment Form Complete and submit this form to enroll for WILD. 1 Get Started 2 Your Info 3 Health Info 4 WILD Info 5 Payment Info Which WILD event would you like to enroll for?* May 12-18, 2012 September 15-21, 2012 Is this an individual enrollment or are you enrolling a group?* I’m attending by myself. I want to enroll a group of people from my organization. Group discounts are available. See them here. If you plan to attend with the group, but you are not the group leader, please have the group leader complete this form and pay/deposit for the whole group. Individual group members will receive a follow-up email with a short form to complete their enrollment details. Including you, how many will be in your group? – 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Enter a valid email address below for each group member that will attend with you. Do not enter your email… you will do that on the next page. We will send an email to each email address you list with a link to a short form to complete their individual registration as part of your group. Email 1* Email 2* Email 3* Email 4* Email 5* Email 7* Email 8* Email 9* Email 10* Email 11* Email 12* Email 13* Email 14* Your Info Name* First Last Organization Address* Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific State Zip Code Primary Phone* Cell Phone Email* Enter Email Confirm Email Gender* Male Female What size t-shirt (unisex) do you wear?* – Small Medium Large Extra Large 2XL Emergency Contact Name* First Last Relationship* – Spouse Parent Employer Other Family Other Primary Phone* Secondary Phone Health Information Do you have any medical conditions?* Yes No If yes, please explain. Do you have any allergies?* Yes No If yes, please explain. Are you taking any medications?* Yes No If yes, please explain. Do you have any dietary restrictions?* Yes No If yes, please explain. Do you have medical insurance?* Yes No Insurance Company Policy Number Enrollment Information Are you enrolling as a for-credit student through one of our partner schools?* No. I’m just here to learn… no credit necessary. Yes. I am enrolling for college, graduate or post-graduate credit. Students that enroll for credit through our contracted partner schools only pay tuition to the school. No deposit payment is necessary to complete this WILD enrollment. Which partner school are you taking the course from?* – Baptist Bible College and Seminary (PA) Faith Baptist Bible College (IA) Northland International University (WI) Davis College (NY) Calvary Baptist Theological Seminary (PA) Which specific course are you enrolling for?* Are you a WILD alumnus?* Yes No What year did you last attend WILD?* 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 or earlier At which WILD Level did you particpate last time?* Level 1 – Learning Level 2 – Informal Leadership Level 3 – Group Leadership Level 4 – Mentoring I don’t remember. Payment Info Which would you like to do today?* I only want to make a DEPOSIT to secure the reservation. I want to PAY THE FULL COST of this WILD enrollment. Individual WILD Enrollment – Deposit* Price: $75.00 Individual WILD Enrollment – Full Tuition* Price: $450.00 Which would you like to do today?* I only want to make a DEPOSIT to secure the reservation for my group. I want to PAY THE FULL COST of this WILD enrollment for my group. How many of your group members do you need to submit deposits for?* Price: $75.00 Quantity: Do not submit deposits for group members that are enrolling for college or graduate credit! For how many group members do you need to submit full WILD tuition?* Price: $425.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $425.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $425.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $425.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $395.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $395.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $395.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $395.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $395.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $395.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $395.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $395.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. For how many group members do you need to submit full WILD tuition?* Price: $395.00 Quantity: Your group rate is based on the TOTAL GROUP SIZE identified at the beginning of this form, including for-credit enrollments, but you should ONLY PAY HERE FOR NON-CREDIT ENROLLMENTS. You’re almost done! This enrollment DOES NOT REQUIRE a DEPOSIT or PAYMENT. Skip this section and click the “Enroll Now” button to complete your enrollment. Please choose your payment method.* – Paypal/Credit Card Bill me. I'll send a check.
