2021 Wilderness Institute (WILD) Enrollment Form Complete and submit this form to enroll for WILD. Select A TripWhich WILD event would you like to enroll for?* May 15-21, 2021 (Appalachian Trail) Oct 10-15, 2021 (Appalachian Trail) 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. 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.Organization* 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 State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone*Cell PhoneEmail* Enter Email Confirm Email Username*Select a username. You'll use this later as a login to access forms and training materials before the trip -- and to connect with us and other trip members after the trip. Gender* Male Female What size t-shirt (unisex) do you wear?*--SmallMediumLargeExtra Large2XLEmergency ContactName* First Last Relationship*--SpouseParentEmployerOther FamilyOtherPrimary Phone*Secondary PhoneHealth InformationDo 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 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?* Yes No What year did you last attend WILD?*--202020192018201720162015201420132012201120102009200820072006200520042003200220012000 or earlierAt which WILD Level did you particpate last time?* Level 1 - Germinating Level 2 - Reproducing Level 3 - Outfitting Level 4 - Widening I 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: Individual WILD Enrollment - Full Tuition* Price: 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: $550.00 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: $525.00 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: $495.00 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: This discount is available to WILD alumni returning within a year of their last WILD event.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 mail a check! Credit Card Credit CardCard Details Cardholder Name Please send your check to: 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.PhoneThis field is for validation purposes and should be left unchanged.