2019 Wilderness Institute (WILD) Enrollment Form - Group Member Complete and submit this form to finalize your enrollment for WILD. This form is only for group members whose group leader already submitted a registration and deposit. If that's not you, enroll here. Which WILD event would you like to enroll for?*May 18-24, 2019Sept 14-20, 2019Your InfoName* First Last OrganizationAddress* 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 Primary Phone*Cell PhoneEmail* Enter Email Confirm Email Gender*MaleFemaleWhat size t-shirt (unisex) do you wear?*--SmallMediumLargeExtra Large2XLEmergency 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 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.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?*YesNoWhat year did you last attend WILD?*201720162015201420132012201120102009200820072006200520042003200220012000 or earlierAt which WILD Level did you particpate last time?*Level 1 - LearningLevel 2 - Informal LeadershipLevel 3 - Group LeadershipLevel 4 - MentoringI don't remember.Payment InfoYour group leader/primary contact already submitted the necessary deposit for your enrollment (if applicable). That person will be responsible for collecting any necessary finances from you and submitting it to us to cover your registration.PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.