One moment please...

 

Wilderness First Aid Certification

August 22nd - 23rd, 2020 (new dates)
Program Registration & Participant Medical Release

Contact Information
*

First Name
Last Name
*

*

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
*
*

*

*

*

*

*

First Name
Last Name
*

*

*

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.
*

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.
*

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.
*

(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.


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.

COVID Policy

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. 
I further acknowledge that Experience Learning has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Experience Learning can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Experience Learning staff.
I voluntarily seek services provided by Experience Learning and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. 

I attest that:
* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the 14 days leading up to this event.
* I have not traveled to a highly impacted area within the United States of America in the 14 days leading up to this event.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. 
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
* I will wear a face mask when requested by the course facilitator.

*

Sign here to indicate that you have read the Medical and Liability Release, and agree to the terms listed above.
*
*
If yes- there is an additional $15 fee due to SOLO. Please pay by check upon completion of the WFA course.
*

COVID updates to course:

PERSONAL PROTECTIVE EQUIPMENT

*You MUST have these items with you in order to attend any of our programs. If you arrive to the course without this gear, the instructor may have options for you to purchase. However, if they do not, you will be asked to leave for the safety of yourself and others in the class.

 2 Face masks (cloth, surgical, N95, or KN95 – needs to fully cover your nose, mouth, and chin)

Eye protection (glasses, goggles, face shield – sunglasses are okay for outside work but please have an alternative for in the classroom)

Hand sanitizer (for personal use only – will not be shared with others)

 

SCREENING QUESTIONS FOR ALL SOLO COURSES

Prior to starting class each day, students will be asked a series of screening questions. With recent events surrounding the COVID-19 pandemic, we feel it is necessary to employ this procedure to help and reduce potential risks to our students and staff. If students indicate any signs or symptoms of being ill at the time of the course, they will be asked not to attend and can work with SOLO to reschedule a training date. Students will receive further detailed instructions on these protocols via email after registering for the course. 

*