2019 Wilderness Institute (WILD) Enrollment Form Complete and submit this form, add it to your cart and complete the checkout process to enroll for WILD. Which WILD event would you like to enroll for?*May 18-24, 2019Sept 14-20, 2019Is 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. They are published in the right column of this page. 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?--23456789101112131415Enter a valid email address below for each group member that will attend with you. Do not enter your email... you will do that in the next section. 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 InfoName* First Last 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 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. No deposit payment is necessary to complete this WILD enrollment.Which partner school are you taking the course from?*--Anchor Christian University (FL)Clarks Summit University (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 - GerminatingLevel 2 - ReproducingLevel 3 - OutfittingLevel 4 - WideningI don't remember.Payment InfoWhich 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: $495.00 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: $450.00 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.WILD Alumni Discount* Price: -$100.00 This discount is available to WILD alumni returning within a year of their last WILD event.PA Sales Tax Price: $0.00 You're almost done! This enrollment DOES NOT REQUIRE a DEPOSIT or PAYMENT. Click ADD TO CART and check out to complete your reservation.Total $0.00 How would you like to submit payment?*I will mail a check!Credit CardPilgrimage 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 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged.