School Year Course- Spring 2022 Registration (12 Weeks)

Rugged Research 12 Week School Year Registration
NOTE: If you are interested in a payment plan, email us at Contact@RuggedResearch.org prior to submitting your child(s) registration form
Student Information
Child's Name *

First Name Last Name
Age *
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent/Guardian Information
Parent/ Guardian Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
E-mail *
example@example.com
If we have a time-sensitive question/ emergency, what's the best number to text you at?
All important communications will happen via email, but if we need to ask you a time-sensitive question or have an emergency that forces us to evacuate the park (inclement weather, injury, etc.) we will send you a text from our satellite phone that has reception everywhere.
List people who are allowed to pick up your child (besides parent/guardian on this form)
Emergency Contact Information
Parent/Guardian Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
E-mail
example@example.com
Child Information
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe. *
Is your child prescribed an inhaler? If yes, please explain any instructions.
Is there a particular learning style that best fits your child?
Names of any siblings or friends you'd like to be grouped with.
What topics is your student most interested in?

Fish Mammals Plants, Trees, Flowers Birds Geology Dinosaurs, Fossils Reptiles and Amphibians Insects Ocean Life Hiking Ecological Interactions
Please describe your child's experience with wilderness experience and hiking skills, if any.
What do you hope for your child to gain or experience by attending?
Is there any other information that you would like to share with us about your child?
Ex: Any medical, learning, behavioral, or emotional challenges that may affect their ability to participate in this program? How does your child interact with other children, adults?
How did you hear about Rugged Research? *

Friend Facebook Instagram Youtube Web/Google search Macaroni Kids Advertisement
Confirmation

BY AGREEING AND ENTERING MY NAME BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Name of Parent/Guardian: *

First Name Last Name
Date *

Month Day Year
Date
Program Selection- (Please click the box below to select the class) *
*Note: No class 4/20 or 4/27
If you are enrolling siblings in the same course, please enter the siblings name below and enter Sib5 in the Promo Code area below for a 5% sibling discount.

My Course

Close Encounters with Nature Course $ 648.00

This 12 week Park Ranger led course meets once a week on Wednesdays for 3.0 hours.

Enter coupon

Subtotal $ 0.00 Tax $ 0.00 Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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Rugged Research 12 Week School Year Registration