WILD Registration Complete and submit this form, add it to your cart and complete the checkout process to enroll for WILD. Which event would you like to enroll for?*Sept 16-22, 2017 - Wilderness Institute - AlgonquinIs this an INDIVIDUAL enrollment or are you enrolling a GROUP?*I'm attending by myself.I want to enroll a group of people from my organization.If you are enrolling as a for-credit student, please select I'M ATTENDING BY MYSELF, even if you are attending with a group. Group discounts are available. They are published in the right column of this page. If you plan to attend with the group, but you are not the group leader, please have the group leader complete this form and pay/deposit for the whole group. Individual group members will receive a follow-up email with a short form to complete their enrollment details.Group Size*Please enter a value greater than or equal to 2.How many total group members are you enrolling, including yourself?Is your organization exempt from PA Sales Tax?*NoYesGenerally, if your organization is a nonprofit or is not in PA, you will be tax exempt for our purposes. If you are not sure, please check with your organization's administration to verify your status.Your InfoName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Cell PhoneEmail* Enter Email Confirm Email Gender*FemaleMaleWhat size t-shirt (unisex) do you wear?*SmallMediumLargeExtra Large2XLWe make every effort to have a t-shirt for each enrollee in the size requested. However, late enrollments and other unforeseen situations preclude us from guaranteeing availability.Do you have a Passport that will be valid through the end date of the WILD event selected?*YesNoTravel to CanadaTo cross the border into Canada and to return to the US, adults must have a valid passport. Generally, it takes 6+ weeks for standard processing and shipping. You may be able to secure a new passport in 3 weeks with expedited processing and shipping... but it will likely cost twice as much.Emergency ContactName* First Last Relationship*SpouseParentOther FamilyEmployerOtherPrimary Phone*Secondary PhoneHealth InformationDo you have any medical conditions?*NoYesPlease explain your medical conditions.*Do you have any allergies?*NoYesPlease describe your allergies... what they are and their severity.*Are you taking any medications?*NoYesPlease list your medications, what conditions they treat and how frequently you take them.*Do you have any dietary restrictions?*NoYesDescribe your dietary restriction(s). Are they prescribed or a lifestyle/preference choice? If necessary, are you able to supplement food provided by the program with foods that fit your dietary requirements?*Do you have medical insurance?*NoYesInsurance Company*Policy Number*Enrollment InformationAre you a WILD alumnus?*NoYesWhat year did you last attend WILD?*--201720162015201420132012201120102009 or earlierAt which WILD Level did you participate last time?*Level 1 - GerminatingLevel 2 - ReproducingLevel 3 - OutfittingLevel 4 - WideningI don't rememberAre you enrolling as a for-credit student through one of our partner schools?*No. I'm just here to learn... no credit necessary.Yes. I am enrolling for college, graduate or post-graduate credit.Students that enroll for credit through our contracted partner schools only pay tuition to the school. No deposit payment is necessary to complete this WILD enrollment.Which school?*Which course?Payment InfoWhat would you like to do today?*I only want to make a DEPOSIT to secure the reservation for my group.I want to PAY THE FULL COST of this WILD enrollment for my group.Individual Deposit Price: $75.00 Group Deposit Price: $75.00 Individual Enrollment - FULL COST Price: $495.00 Individual WILD Alumni Discount Price: -$100.00 Group Enrollment (2-5) - FULL COST Price: $0.00 Group Enrollment (6-9) - FULL COST Price: $0.00 Group Enrollment (10+) - FULL COST Price: $0.00 How many individuals in your group, including you, attended WILD within the last 12 months?Group WILD Alumni Discount Price: $0.00 Subtotal Price: $0.00 PA Sales Tax (Organization) Price: $0.00 PA Sales Tax (Individual) Price: $0.00 Total Due Today Price: $0.00 How would you like to submit this payment?Credit CardI'll mail a checkPlease mail your check to: Pilgrimage, 17051-3 Emile St, Boca Raton, FL 33487.Your enrollment will be official when payment arrives at the office and is recorded.This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged.