NOLS Wilderness Medicine Course Registration

Course Registration Form

Finalise your course registration on a Crossing Latitudes sponsored NOLS Wilderness Medicine course by filling out this form. A separate reservation must be filled out for each participant.
Name*

First NameLast Name
Birth Date*

DayMonthYear
Gender
For room allocation (if relevant)
Email*
example@example.com
Phone number*

Country CodeArea Code (enter "0" if N/A)Phone Number
Mailing Address (WFR participants- this is where we will post your textbook to)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Nationality*
Company

Recertification

Note: Eligible graduates from other providers may recertify on our Wilderness First Responder Recertification course, or our Wilderness Advanced First Aid course. To be eligible for recertification you must possess a current (unexpired) WFR certification from a provider whose programming meets or exceeds the guidelines established by the Wilderness Medicine Education Collaborative (WMEC). WFR courses with a minimum of 70 hours of total instruction and a minimum of 45 hours of in-person instruction will be recognised. NOLS Wilderness Medicine does not recognise certifications from entirely online training.
Are you recertifying your NOLS Wilderness First Responder (WFR) or NOLS Wilderness Advanced First Aid (WAFA) on this course?*

Yes - I am a NOLS WFR or NOLS WAFA graduateNo
Are you recertifying your Wilderness First Responder (WFR) or NOLS Wilderness Advanced First Aid (WAFA) on this course?

Yes - I am a NOLS graduateYes- I am an eligible non-NOLS WFR graduate

Logistics
Date of Arrival*

MonthDayYear
Date
Date of Departure*

MonthDayYear
Date
Transportation*

I will be driving/ travelling to the course on my own (NO carpooling)I am driving and am willing for other students to carpool with meI would be interested in carpooling/ shared transport service with other students if the option is available
As you have selected interest in carpooling, please confirm that you are willing to be put in contact with other students.

I confirm that Crossing Latitudes may put me in touch with other students for carpooling
Cassibile WFA: I would like to sign up for the accommodation package if available. I acknowledge that this is not a confirmation of booking and Crossing Latitudes will contact me if there is availability. Accommodation costs €30 per night for a total of €90 and is in shared accommodation.

YesNo

Medical Information

A key tenet of wilderness medicine is prevention. Please fill out this medical section so that we can support you during our course and prevent medical emergencies.
Medical Concerns: Please list any medical concerns that you may have (e.g. Diabetes, asthma, seizure disorder, cardiac conditions, musculoskeletal injuries, etc.) and please indicate if you have any emergency medication for this condition.
Allergies: Please indicate if you have any allergies (to medication, food, animals, environment, etc.) and do also indicate if you take any medication for your allergies (e.g. antihistamines, epinephrine/adrenaline, etc.) Kindly also indicate what happens when you have an allergic reaction (e.g. rashes, swelling of airway, fainting, etc.)
Emergency Contact Information*

First NameLast Name
Phone Number*

Country CodeArea Code (enter "0" if N/A)Phone Number
Relationship with emergency contact*

Family memberFriendPartnerWork contact
Email address of emergency contact
example@example.com
Primary Doctor (if relevant)

First NameLast Name
Phone Number of primary doctor

Country CodeArea Code (enter "0" if N/A)Phone Number
Email of primary doctor
example@example.com

Payment
I wish to pay by*

Credit cardPlease provide me with an invoice (note that payment is required to secure your place on the course)Other
If you have selected other, kindly describe how your course will be funded. (e.g. you are a NOLS instructor and this is organised through NOLS/ you are a part of the lyftkraft 2.0 programme which is funding your first aid training/ etc. )
Please name the invoice to:
Your name/ name of the organisation the invoice should be named to
Email for invoice (if not the same as registrant email)
example@example.com
Address for Invoice (if not the same as mailing address above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number (if not the same as registrant phone number)

Country CodeArea Code (enter "0" if N/A)Phone Number

Thank you!

Please press submit to complete your registration. We will be in touch with you shortly.
You will now be redirected to the credit card payment form.
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Course Registration Form