Join Wilderness Girls

Wilderness Girl's Name

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent's/Guardian's Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email

Phone

Physical Girls of

Allergies or Medical Conditions

e.g. asthma or epilepsy

Special Dietary Conditions

Additional Physical or Emotional Support Conditions

e.g. physical disabilities, Autism, ASD, ADHD

I allow my child to be photographed during Wilderness Girls events.

Yes
No

I agree to have my phone number shared with other Wilderness Girls parents.

Yes
No

By signing, I agree to the holding of this information and understand the Wilderness Girls will not pass information onto third parties without prior permission. The information I have provided is correct as of the date signed.

Signature

Clear Signature

Date