NAME *

Unless otherwise specified below, the individual who submits this form will be considered the primary contact for this event / program.

First Name

Last Name

PHONE *

(###)

###

####

START DATE *

MM

DD

YYYY

END DATE *

MM

DD

YYYY

START TIME *

Hour

Minute

Second

AM PM

END TIME *

Hour

Minute

Second

AM PM

Location Address For Event *

Specific address of event location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Location Address Meeting Place

If meeting before the event or caravaning to the event location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Field Trip Leader Name *

First Name

Last Name

Distance *

(select one): Aside from the use of your car, we will travel _____miles (required) total during this event.

0 miles; Big Sit; Other Event

Up to 0.25 miles

Up to 0.50 miles

Up to 1.0 mile

Up to 2.0 miles

More than 2.0 miles

Travel surfaces / terrain (select all that apply) *

Pavement

Gravel

Soft Sand

Hard-packed dirt/sand

Muddy or wet surfaces

Boardwalk

Short grass

Tall grass/weeds

Trail Steepness (select one)

Mostly flat

Slight uphill / downhill changes

Moderate uphill / downhill changes

Steep uphill / downhill changes

Is this event suitable for (check all that apply) *

Wheelchair users

Walker users

Cane or hiking pole users

Restrooms: Please specify if these are accessible facilities or if restrooms are primitive / portable toilets. *

Yes- Primitive

Yes- Accessible

No

Are there Benches / Places to Rest *

Yes

No