Wilderness
First Responder Application
WMA
will be conducting this WFR training at the Sheridan School Mountain Campus in
Luray, Virginia on June 21st- June 28th, 2008. The cost
for this course will be $640 a person and the tuition will include the course
and all required materials as well as food and lodging.
By signing up for this
course the participant will agree to pay the full amount, $640, prior to the
start of the course. A deposit of $150 will be required for registration to
guarantee a spot in the course. This deposit will be fully refundable if the
Mountain Campus is notified no less than 1 full month (May 21st) prior to the
start date of the course. A refund of 50% of the deposit is available if the
Mountain Campus is notified no less than 2 weeks (June 7th) prior to the start
of the course, and no refunds will be issued after that point.
Along with the deposit
of $150 please include this Wilderness First Responder Application filled out
in its entirety. We will be unable to guarantee a spot without all of the
aforementioned information.
Please note that the
provided accommodations will be canvas platform tents with supplied bunk beds,
however, each participant will be responsible for their own bedding. All meals
will be provided in the campus-dining hall and will be served cafeteria style.
Please make a note in the appropriate section of any food allergies or special
accommodations that need to be taken into consideration, such as vegetarian.
This course
will include both written examinations and skill demonstrations to pass. You
must pass all exams and skills test with at least a score of 80% or better.
100% attendance is also required to pass this course. No refunds will be given
if a failing grade is achieved.
__________________________________ _________________________
Signature Date
__________________________________
Printed Name
Wilderness
First Responder Medical Form
WMA
will be conducting this WFR training at the Sheridan School Mountain Campus in
Luray, Virginia on June 21st – June 28th, 2008. The cost
for this course will be $640 a person and the tuition will include the course
and all required materials as well as food and lodging.
The
information requested below is private data.
The data will be used in the event you require emergency medical
treatment by other persons administering first aid or by medical personnel. You may refuse to supply the requested
information; however, failure to provide the data will hamper the giving of
emergency medical treatment. Regardless
you need to fill out the general information and sign the release.
Name
_____________________________________________________________ Gender: Male Female
Address
_____________________________________________________________________________________________
Age Date of Birth _____/_____/_________
EMERGENCY CONTACT
INFORMATION
Primary Contact Person
in Emergency ____________________________________ Relationship __________________
Home Phone
_____________________ Cell Phone?______________________ Work
Phone______________________
Address__________________________________________________________________________________________
Secondary Emergency
Contact ____________________________________
Relationship ________________________
Home Phone
_____________________ Cell Phone?______________________ Work
Phone______________________
Address__________________________________________________________________________________________
MEDICAL INSURANCE
INFORMATION (optional)
Carrier:___________________
Policy Number:__________________ Primary Insured’s Name:__________________
Group number (if
applicable):__________________
Any Health / Medical /
Allergies matters we should be aware of:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Dietary Restrictions if
any
______________________________________________________________________________________