Complete and submit the form below to enroll for the OCTOBER 10-13 WILDERNESS EVENT over Fall Break. Your InfoName* First Last Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Email* Enter Email Confirm Email Gender*MaleFemaleWhat size t-shirt (unisex) do you wear?*--SmallMediumLargeExtra Large2XLDepending on the group size, we MAY be able to make event t-shirts. Just in case, let us know what size you would want.Emergency ContactName* First Last Relationship*--SpouseParentEmployerOther FamilyOtherPrimary Phone*Secondary PhoneHealth InformationDo you have any medical conditions?*YesNoIf yes, please explain.Do you have any allergies?*YesNoIf yes, please explain.Are you taking any medications?*YesNoIf yes, please explain.Do you have any dietary restrictions?*YesNoIf yes, please explain.Do you have medical insurance?*YesNoInsurance CompanyPolicy NumberEnrollment InformationAre you enrolling for a CSU course?*Students that enroll for credit through our contracted partner schools only pay tuition to the school. No deposit payment is necessary to complete this event enrollment. This event has an enrollment limit. Students enrolled for CSU courses will be given priority. Non-credit students will be assigned to any available spots in the order they enrolled via this form. THIS EVENT IS ONLY AVAILABLE TO ON-CAMPUS CSU STUDENTS.Yes. I am enrolling for a CSU course.No. I'm just here to learn... no credit necessary.Which specific course are you enrolling for?*PE400 Learning Activities, Games & EventsEM340 Intro to Accelerated LearningEM350 Wilderness LeadershipOL501 Leading in Active Learning Environments (Graduate Level - MA Program)I need help selecting the appropriate course.Have you attended a Pilgrimage Wilderness Institute (WILD) event in the past?*YesNoWhat year did you last attend WILD?*--201720162015201420132012201120102009200820072006200520042003200220012000 or earlierPayment InfoWhich would you like to do today?*I want to PAY THE FULL COST of this event enrollment.Individual CSU AT Event Enrollment - Non-Credit* Price: $495.00 FL Sales Tax Price: $0.00 You're almost done! This enrollment DOES NOT REQUIRE a DEPOSIT or PAYMENT. Click ENROLL NOW to complete your reservation.Total $0.00 How would you like to submit payment?*I will pay by check.Credit CardYour registration is NOT COMPLETE until full payment is received. To ensure your spot, please consider paying via credit card.Pilgrimage 8854 SW 11th St Boca Raton, FL 33433 *Your registration won't be complete until at least a deposit is received in the office.Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged.