City of Topeka - Edventure Registration Form

Mike Coker, Director

Topeka Zoological Park - Map
635 SW Gage Blvd
Topeka, KS 66606
785-368-9131
785-368-9152 FAX
mcoker@topeka.org

Zoo Administration office
785 368-9180

Recorded information line
785 368-9140
785-368-9152 Fax

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Zoological Park | Edventure Registration Form

Name of Class: Date of Class

AM or PM

Students Name Age Sex

Address: City: Zip:

Parent/Guardian:

Work Phone: Home Phone: Cell

Do you or your child require a reasonable accommodation in order to participate in the program? Requests must be made 2 weeks (ideal) in advance by filling out a Special Needs Statement and Request Form.

Emergency Contact 1: Phone:

Emergency Contact 2: Phone:

The following individuals are authorized to pick up my child:

Parent/Guardian Signature: Date:

Child's Physician: Hospital Preference:

Please list all allergies your child has:

Please list all medications your child is taking and please note which prescription or over the counter meds they will need to take during the time of the program
(Please note: zoo staff are not responsible for providing, giving, storing, or applying any prescribed medications or treatments)

FOTZ member?:

*Refunds will be made only if the class is full or is cancelled by the Education Department.

The zoo is going green! If you would like to help conserve paper by having your confirmation information emailed to you, please provide your email address:

This web site and its contents are maintained by the City of Topeka, KS., I.T. Department. Unauthorized use is prohibited by law. Contact the I.T. Department with questions or suggestions. All material contained on this web site is © 2009.

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