PROGRAM APPLICATION
(All personal and medical information will be kept in strict confidence)


ONE APPLICATION PER PROGRAM, PER PERSON.

A CREDIT CARD INFORMATION FORM AND RELEASE OF LIABILITY WILL BE EMAILED TO YOU UPON RECEIPT OF THIS RESERVATION.  YOU WILL NOT BE REGISTERED FOR THE CLASS UNTIL WE HAVE RECEIVED THE RELEASE AND THE CREDIT CARD PAYMENT HAS BEEN PROCESSED.

Name*
Child Name (if applicable)
Mailing Address*
City, State*
ZIP*
Daytime Phone (with area code)*
Cell Phone (with area code)*
Home Phone (with area code)
Email*
Are you over 18? If not, please list age.*
Are you a Zoo member?*
If yes, please list your member # and expiration date:
Do you have any of the following? (check all that apply and detail below if necessary)









Please detail any medical conditions checked above:
Name and date of workshop for which you are applying:*
Please answer the simple math question below to submit the form.
2 + 2 =