2027 NOLS Wilderness Medicine Course Registration Form

2027 Course Registration Form

Register for a Crossing Latitudes organised 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
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Nationality
Company (if applicable)

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?
Are you recertifying your Wilderness First Responder (WFR) or NOLS Wilderness Advanced First Aid (WAFA) on this course?

Logistics
Date of Arrival

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Departure

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Transportation
As you have selected interest in carpooling, please confirm that you are willing to be put in contact with other students.

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
Email address of emergency contact
example@example.com
Primary Doctor (only 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 (you will receive a receipt for your payment regardless of method)
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 a 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
VAT number (if applicable):
The VAT number of the organisation the invoice is named to.
Reference number (if applicable):
Reference number that should be listed on the invoice (only if applicable)
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.
Thank you!

You will now be directed to the credit card payment page
Thank you!

Please press submit to complete your registration on the waitlist. We will be in touch with you shortly.
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2027 Course Registration Form