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Wilderness First Responder Certification

Program Registration & Participant Medical Release

Contact Information
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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First Name
Last Name
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Please list any allergies known, including dietary restrictions and food allergies, vegetarian, lactose intolerant, etc. We always have vegetarian options, and will do our best to accommodate allergies, etc. Please be specific.
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List all medications that you are currently taking. Bring all prescription medications with you in their original containers with physician’s dosage directions. If you are bringing an Epipen, please bring two, as well as the appropriate dose of oral Benadryl due to our remote location.
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Please list all medical conditions that you have been diagnosed or treated for within the past year. If diabetic, please include contact information for diabetic nurse/physician.
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(mm/dd/yyyy)
Permission to use Images

Experience Learning relies on the use of images of program activities and student feedback for recruitment purposes, as well as to report to and solicit financial donors. Staff members often take photographs informally throughout a program and these serve as our image library. Also, students are asked to complete evaluations at the end of a course. By signing below you agree that Experience Learning has the right to use pictures or statements by, of, or about you for aforementioned uses.


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Nondiscrimination Policy

Experience Learning follows a policy of uniform nondiscrimination.

Medical and Liability Release

I understand that Experience Learning programs may involve canoeing, hiking, camping, backpacking, stream sampling and other outdoor activities. I understand the inherent risks involved in these activities and that unanticipated dangers may arise. I voluntarily assume all risk of loss, damage, illness or injury, including death, which may occur while I am participating in any activity or event associated with Experience Learning or during such times as I am under the supervision of any employee or agent of Experience Learning. I agree to hold harmless and release Experience Learning and its volunteers, employees, and agents in any location where activities are conducted. If a medical emergency does occur in route to or from or while participating in Experience Learning programs and I cannot readily be reached, Experience Learning may select any licensed physician to secure and administer medical treatment, including hospitalization and surgery for the child if and as needed. I understand any medical expense so incurred will be my financial responsibility. I have listed all the information concerning allergies, medical history or conditions, dietary restrictions and regular medication that I may take.

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Sign here to indicate that you have read the Medical and Liability Release, and agree to the terms listed above.
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**We require a 15% deposit ($101.25) with the submission of this form. The remaining balance to be paid 2 weeks prior to the program start date. If you cancel we will retain this deposit as a non-refundable cancellation fee. If Experience Learning or SOLO cancels the program for any reason, you will receive a full refund.
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Deposit is due to ensure space in class.