Enrollment Form and Medical Form

WILDERNESS FIRST AID

Enrollment Form and Medical Form

Pine Point Fire Station, Scarborough, Maine

May 5 and 6, 2012

PLEASE PRINT LEGIBLY:

Name: ______

Address: ______

Telephone: ______(home) or ______(cell)

E-mail: ______Today’s Date: ______

Your E-mail will be used for purposes of this and future WFA courses. It may also be used for Chapter communications.

SPECIAL CONSIDERATIONS?

Please let us know if you have special needs we should know about prior to the course.

Health History: Please provide any medical issues or considerations which the course instructors should be aware of. (For example, severe allergic reaction to bee stings.)

Medications:

Emergency contact person:

Name: Address:

Are you an AMC member? Circle one: Yes No AMC membership #______

(# is on member card, AMC Outdoors label and is provided when you log into the AMC’s Member Center) If you just joined, a copy of your receipt from online payment.

Participation Costs

·  If you are a recognized Maine Chapter AMC leader in good standing, the cost for the session is $20. Your registration fee will be returned upon successful completion of the course.

·  If you are a Maine Chapter AMC member, the cost for the session is $35.

·  If you are an AMC member but not a Maine Chapter AMC member, the cost for the session is $60.

·  If you are not an AMC member, the cost for the session is $100 (Join now! See note).

Note:

Non-AMC members can reduce their cost for the session by becoming Maine Chapter AMC members. AMC individual membership cost is $50 ($40 on-line option-see instructions below). Those wishing to become Maine Chapter members and to attend this Wilderness First Aid session, please join the AMC through the Maine Chapter website at least a week prior to the course. Chapter affiliation may be changed through the AMC’s on-line member center.

For the membership price, you get a subscription to the AMC Outdoors, the Maine Chapter newsletter Wilderness Matters, and discounts on AMC lodging, workshops and books.Best of all, half of the membership fees come back to the Maine Chapter to fund Maine projects!

You must return your completed registration form and check(s) for the appropriate registration fee, payable to: Maine Chapter – AMC.

Mail completed registration forms and check(s) to:

Michelle Moody

237 Foreside Road, Topsham, ME 04086

email:

NOTE: IF THE CLASS FILLS AND THERE IS A WAIT LIST AND WE DO NOT RECEIVE YOUR CHECK BY APRIL 20, YOUR SPOT MAY BE RELEASED TO THE NEXT PERSON ON THE WAIT LIST. AFTER APRIL 20, YOU WILL ONLY BE REGISTERED FOR THE COURSE IF WE HAVE YOUR CHECK.

WFR (Wilderness First Responder) or WEMT:

Do you plan to re-certify your WFR or WEMT?

We must notify SOLO in advance of April 30, 2012, if you plan to re-certify.

If this applies to you, please bring a copy of your current CPR, WFR and/or WEMT certifications with you on the dates of the workshop. There may be an additional charge by SOLO. If so, you will be asked to pay directly to SOLO on the date of the workshop.

Maine Chapter Membership for New Members

If you would like to join the Maine Chapter, you can do so at the AMC Maine Chapter website (www.amcmaine.org, under ‘Become a Member’ at the right of the site, select Join the AMC). If you join through the chapter web site, first time members will receive a 20% discount off normal membership prices! In addition, more dollars stay with the Maine Chapter. You can pay online immediately and your membership will be active in about two days