Education Program Registration Form

Parent/Guardian Information

 

Parent/Guardian's Name: _______________________________ Address: _____________________________________________
City: _____________________________________ State: ______ Zip: ___________________ 
Phone (day): ___________________________ Phone (eve): ___________________________
Are you an Oregon Zoo Member? _____No    _____Yes     If yes, what is your member number? _____________________
If you would like to be an Oregon Zoo member, please call 503-220-2493 for more information.


This form can be faxed to 503-220-5712. Please attach additional sheets of paper as necessary.
  Class Name Class Date Fee
Class Title      
Adult Participant  
Child Participant   Date of Birth :
  Class Name Class Date Fee
Class Title      
Adult Participant  
Child Participant   Date of Birth :
  Class Name Class Date Fee
Class Title      
Adult Participant  
Child Participant   Date of Birth :
  Class Name Class Date Fee
Class Title      
Adult Participant  
Child Participant   Date of Birth :
Payment Information
Tax deductible donation for Tuition Assistance program:
$__________
Total Amount Enclosed
$__________
Payment enclosed: Check (Payable to Oregon Zoo) Visa MC AMEX 

Credit Card Account Number: ____________________________________ Security Code: _____ Expiration Date: _____________
Note: Security Code is on back of credit card
In the event that my class choice is full, I would prefer: (select one only)
 to keep a class credit on file                a cash refund by mail                a credit back to my charge card