Gr 5 & 6 - 06.19.23 #Conservation

Child Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• Cell Phone:
• * Age
• * Grade Completed this May --Choose-- 5th 6th
• * Shirt Size --Choose-- Youth Small Youth Medium Youth Large Youth XL Adult Small Adult Medium Adult Large Adult XL

• Fee

  Type	Fee
  Non-Member	$150.00
  FOTAZ Member	$130.00

Allergies or Restrictions

• * List any allergies or restrictions.

Additional Child Information

You may add a maximum of 2

Parent / Guardian Info

• * Parent / Grandparent / Guardian Name
• For FOTAZ Members: Expiration Date
• * Emergency Contact Phone Number
• * Campers will only be released to those listed here (this list can be updated during the camp week). Please list the first and last name of persons authorized to pick up your child(ren).
   characters remaining

• By submitting this form, I understand that Alexandria Zoological Park may use pictures and/or video of my child(ren) taken during Summer Safari for promotional and news purposes.

• All campers will receive a shirt. However, for registrations received after May 10, shirt size is not guaranteed.