Trip Registration

Participant's Name
Street Address
City
State
Zip Code
Birthdate
Parent/Primary Caregiver (if under 18)
Parent's Cell Phone
Parent's Home Phone
Parent's Work Phone
Email Address
Medical Concerns/Allergies
Emergency Contact - Name and Phone Number
Select Trip
Pine Ridge Trip - Cost $500 per person
I give my child permission to participate in this program. this box, The leaders will not be held responsible for injury, etc.
I agree.
(over 18) I understand that by checking this box I agree to participate in this program and will not hold the leaders responsible for injury, etc.
I agree.