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Coyote Club Fall Session
Thank you for your interest with our program.
Tuesdays 4:30-6:30
Sept. 10, 17, 24
Oct. 1, 8, 15, 22, 29
Nov. 5, 12, 19
at Merrill Park in Eagle
Any questions? Call 208-860-0728
Maria Anderson
www.coyoteconscience.org
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Participant's Name
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Nickname
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Date of Birth
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Describe your child. What are they like? What are their challenges? Any special needs? Emotional sensitivities?
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What do you hope your child gets out of this program? How will it benefit them?
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How did you hear about us?
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Do you have any concerns about a fully outdoor program rain or shine?
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Mailing Address
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Parent/Guardian Name and Phone Number
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Parent/Guardian Name and Phone Number
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Emergency Contact 1: Name and Phone Number
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Emergency Contact 2: Name and Phone Number
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Please provide any information about individuals your child has permission to leave with, including names and relationships, and any other additional information that might be helpful.
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Medical Information including allergies and medications
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Non-refundable deposit of $50 is required to hold your child's spot. Price for this program is $250. Program meets
at Merrill Park. Tuesdays 4:30-6:30. Please do not send payment until you receive a confirmation email.
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Venmo: coyote_conscience
Paypal:
info@coyoteconscience.org
Check send to: Coyote Conscience, 272 S. Kestrel Pl., Eagle, ID 83616
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