Wilderness Medicine Registration

First Name:
Last Name:
Street Address:
Apartment Number:
City:
State:
Zip:
Phone Number:
E-Mail:
Course(s):	All Courses include book! Basic Wilderness First Aid $60.00 Wilderness First Aid $100.00 Wilderness First Responder Program $675.00 Wilderness EMT Add-On Module $500.00
Total Cost:	(Full Payment Required)
Find a class in our schedule then enter the date you want to attend below.
Course Date:	(MM/DD/YY)
Name on Card:
Type of Card:
Card Number:
CSC:
Expiration Date:	(MM/YY)
	I understand that my credit card will be charged the amount above upon receipt of registration form.
Please Initial: