RtN Event Registration Form

ROOTED THROUGH NATURE LEARNING CENTER

Please allow 24-48 hours to review and respond to this form. For a faster response please feel free to call 413-356-0557 or email info@rootedthroughnature.com
STUDENT REGISTRATION

For trial days or events only!!
Student's Name*

First NameLast Name
Date of Birth:

MonthDayYear
Date
Additional Student's Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Parent's Name

First NameLast Name
Parent's Name

First NameLast Name
Address*

Street Address

Apt or unit number

CityState

Zip CodeCountry
Phone Number
Please include area code
Can you receive texts on this number?

YesNo
Email
example@example.com
Would you prefer a follow-up email or text?

CallEmail
Last school attended:
Please verify that you are human*
Should be Empty:

ROOTED THROUGH NATURE LEARNING CENTER