WILD Registration – 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. Select A TripWhich WILD event would you like to enroll for?* May 23-28, 2022 (Appalachian Trail) Other Your InfoName* First Last Organization 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 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.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?*2021202020192018201720162015201420132012201120102009200820072006200520042003200220012000 or earlierAt 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 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.CommentsThis field is for validation purposes and should be left unchanged.