Intro To Outdoor Bouldering Summer 2022

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.

Please describe your child's experience with bouldering.

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? *

Facebook Instagram Word of Mouth 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 *

Date

Class Time Selection

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. Each sibling must have their own registration form.

My Products

Intro to Outdoor Bouldering $ 25.00

Classes will take place at Rotary Park (next to Horsetooth Reservoir) in Fort Collins

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

Please verify that you are human *