City of Topeka | Topeka Zoological Park: EdZooCation Edventure Registration Form

Topeka Zoological Park	+ Larger Font + Smaller Font
Michael D. Coker, Zoo Director Topeka Zoological Park - Map 635 SW Gage Blvd Topeka, KS 66606 785-368-9131 785-368-9152 FAX mcoker@topeka.org

Note: Some fields are required

Name of Class: Date of Class

AM or PM

Students Name Age Sex

Shirt Size: (Camp Peka Sue Only)

Address: City: Zip:

Parent/Guardian:

Work Phone: Home Phone:

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.

In Case of Emergency call: Phone:

The following individuals are authorized to pick up my child:

Parent/Guardian Signature: Date:

Child's Physician: Hospital Preference:

Please list all allergies and medications:

FOTZ member?:

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

Notice: The number displayed below is to confirm entry submission.

6957

Type confirmation number (above in red) here

Email Address

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