WaterWays Outdoors
Participant Course Registration
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
What course are you taking?
Please Select
Wilderness First Aid
Advanced Wilderness First Aid
Advanced Wilderness First Aid - Part 2
Wilderness First Responder
Wilderness First Responder Recert
Heartsaver CPR
BLS CPR
Stop The Bleed
Basic Canoeing 1-3
Basic Canoeing 4
Basic Canoeing 1-4
Canadian Style Paddling 1
Canadian Style Paddling 2
Canadian Style Paddling 3
Are you taking CPR as well?
Yes
No
Course Start Date
-
Month
-
Day
Year
Date
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Medical Information
Do you have any of the following?
None
Heart Disease
Asthma or other Respiratory Disease
Diabetes
High Blood Pressure
Seizures
Arthritis
Headache/Migraine
Anxiety/Depression
Hearing Impairment
Vision Impairment
Other
Do you have any problems with mobility?
Yes
No
Allergies
Yes
No
Please List Allergies
What happens if you have contact/ingest the allergens?
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Emergency Contact Information
In case of illness/injury the person who should be contacted if I am unable to is:
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Email
example@example.com
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Consent #1
I agree that the information provided on this form is, to the best of my knowledge, accurate. It is also understood that the information provided on this form is confidential and will not be shared with anyone beyond the course instructors/directors and medical personnel who may be caring for me in the event of illness or injury.
Signature
Date
-
Month
-
Day
Year
Date
Consent #2
I consent to the course instructor contacting the emergency contact I listed on this form in the event I am ill or injuried and am not able to do so myself.
Signature
Date
-
Month
-
Day
Year
Date
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