11/20 Close Encounters: Awesome Autumn

Close Encounters with Nature: Awesome Autumn!

A drop off only class for ages 7-11
Let's get outside and explore Kentucky in the fall!

Location: Lexington city parks- exact location will be emailed out upon registration.

Date/Time: Sunday, November 20th. 1-3pm

Cost: $30 per student
Student Information
*A separate registration form must be completed for each child
Child's Name *

First Name Last Name
Age *
Gender *

Male Female
T-shirt size
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Siblings:
If you are signing up siblings together for the same session, please enter Sibs5 for the promo code at checkout on both registration forms in order to recieve 5% off. Please list sibling if applicable:
Sibling's Name
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.
List people who are allowed to pick your child up from class (besides parent/guardian on this form)
Emergency Contact Information
Emergency 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.
What do you want your child to gain from this class?
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 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

My Products

Awesome Autumn (7-11) $ 30.00

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Subtotal $ 0.00 Tax $ 0.00 Total $ 0.00

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Close Encounters with Nature: Awesome Autumn!