Registration Form

Wild Wild West Reading Rodeo

Participant Registration Form
Registration Fees can be paid online securely through Give Lively and must be completed in order to complete the registration process. You will be redirected to the payment site after you submit the camper registration.

Note: After being redirected to the payment site, If you choose "Add NewBank Account" but are unable to locate your bank, please then choose the "Add New Credit Card" button and proceed with payment.

If you are unable to pay the full registration fee, please contact Beth Zarnke at 715-897-7187 or email Memorylanefarm86@gmail.com for a Scholarship Application prior to completion of the registration form below.

Only one child may be registered at a time.
Participant Information
Child's Full Name*

First NameLast Name
Desired Program (Grade Entering Fall 2023):

June 6, 7, 8: 9am-11:30am (1st-2nd Grade) Cost: $112June 20, 21, 22: 4:30pm-7pm (3rd-4th Grade) Cost: $112July 11, 12, 13: 4:30pm-7pm (5th-6th Grade) Cost: $112
E-mail Address where you'd like to receive confirmation and information:*
name@gmail.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Birth Date*

MonthDayYear
Current Age:*
Grade Entering Fall 2023*
Gender:*

MaleFemale
EMERGENCY INFORMATION
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship:*
Emergency Contact Phone Number:*
List any allergies or sensitivities: (medical, food, etc.): (If none, enter none)*
List any chronic illness and or physical limitations camp should know about: (If none, enter none)*
Current Date:*

MonthDayYear
Date
Should be Empty:

Wild Wild West Reading Rodeo

Participant Information

EMERGENCY INFORMATION