To apply for one of our adventures, please submit an $800 deposit with this completed application form. Full tuition payment is due on March 1st. Because space is limited, we encourage you to submit your application as soon as possible to Wilderness Ventures. If you have any questions please call us at 800-533-2281 or 307-733-2122 or email us at info@wildernessventures.com.

Student Information
Legal First Name:
Preferred First Name:
Last Name:
Home Address:  
City: State: Zip:
Home Phone: ex: 307/733-2122
Fax Number:
Student Email:
Birthdate: ex: 1/15/1993
Age at start of trip: years.months ex:15.4
Height:
 feet   inches
Weight:
 lbs.
Gender:
T-Shirt Size:
  (Adult Sizes)
School Name:
Grade: (completed at start of trip)
Passport Information:

(only applicable for Alaska Southeast, Alaska Service and All International Trips.)
 
Name as it appears on your Passport:  
Passport Number:  
   

Father

 
Father's Name:
Occupation:
Address:
City: State: Zip:
Home Phone: ex: 307/733-2122
Business Phone:
Cell Phone:
Email:

Mother

  
Mother's Name:
Occupation:
Address:
City: State: Zip:
Home Phone: ex: 307/733-2122
Business Phone:
Cell Phone:
Email:
Applicant lives with:
If two household family, please mail correspondence to:
If other please specify:
 
Tuition paid by:    
If other please specify:
 
   

Names and Ages of Siblings

First Sibling
(Name)     (Age)
Second Sibling
(Name)     (Age)
Third Sibling (Name)     (Age)
Forth Sibling
(Name)     (Age)
Do you have any dietary restrictions?    
If so, please explain:

 


References

References: We require the name and phone number of two teachers, coaches, or advisors who may be contacted as a personal reference.

Name of Teacher:     Email:

Work Phone: ext:

Name of Teacher:     Email:

Work Phone: ext:

Program Information

Please list your first two choices

First Choice:

   Do you plan on attending with a friend?:  

Second Choice:

   Name:  
   
  Have you ever participated with Wilderness Ventures before?: If so, which trip(s):
The following persons may be interested in receiving a brochure:
 

Payment Information
  A deposit of $800 is required to apply to one of our expeditions.  
Credit Card Type:  
Credit Card Number:  
Exp Date
 
Name on Card: :  
Security Code
 Please charge the $800 deposit to my credit card.
Billing Address :  
Billing City :
  
Billing State  
Billing Zip :
 
  I have already submitted my credit card information via phone. Date      

I have read, understand and agree to Wilderness Ventures' Important Details.
Click Here to read these Important Details, which include:
Admissions Payments, Withdrawals, and Refunds
Expectations Rules and Regulations
Communication Personal Electronics
Group Placement Health Report
Alterations to Itinerary Food
 
Applicant Initials: