Advanced Response Training - Registration Form

		Wilderness, Urban and Aquatic Rescue Training Registration Form

About Us Aquatic Programs Urban Programs Wilderness Programs Course Schedules Registration Contact Us		To Register: To register for a course simply print off this page, complete all sections and send it along with your course payment (cheque or money order) to: Advanced Response Training 1784 Cross Street Innisfil, Ontario L9S 4M1 OR complete the On-line Registration Form soon to be available A confirmation package will be sent to you shortly after receiving your registration and payment.
		Personal Information Name: ______________________________________________________ Permanent Address: ____________________________________________ Phone Number: ( ) _____ - ________ Email Address: ________________________________________________
		Medical Information Date of Birth: ____ ____ ________ Age: _____ Health Card / O.H.I.P. __________________________________________ Emergency Contact During Course Name ______________________ Phone ( ___ ) ____- _______ Do you have... Please Explain (if yes) allergies _____________________________________________ medical condition ______________________________________ Is there any other medical information that our staff should know about ? __________________________________________________________ __________________________________________________________
		Course Information Course Name: ________________ Course Date: ___ ___ _____ Transportation is each participant's responsibility however, sometimes it is possible to arrange transportation for those who do not have their own methods. Please help us by answering the following: Do you have your own transportation to/from the course? Would you be willing to provide car pooling for other participants? Full payment is required at the time of registration. A full refund or transfer to another course will be made if program is cancelled due to instructor illness or low enrollment. If a participant withdraws from a program up to 10 days before the start date, a full refund (minus a $20 admin. fee) or transfer to another course will be made. Transfers are only valid during the same program year.
		Wilderness Program Participants ONLY: Please Provide a Second/Back Up Emergency Contact: Name: ________________ Phone: ( ___ ) _____ - ___________ Do you have any special dietary requirements? Please explain. ______________________________________________ Note: We make efforts to accommodate various special dietary requirements within our regular meal plans. To help off-set any additional expenses associated with some meal plan adjustments, there MAY be an additional cost. Please contact our office to discuss your dietary requirements and possible additional costs.
		Please Read and Sign the Following: (if participant is under 18yrs, parent/guardian must sign) Release, Acknowledgement and Assumption of Risk: I understand that the instructors conducting the Advanced Response Training programs have taken precautions to provide adequate organization, supervision and instruction for this course. I understand and acknowledge that the instructors are unable to guarantee my absolute safety and I agree to abide by the instructions and directions given to me by them. I hereby assume all of the risks that may come about, by accident or in any other way connected with my participation in the course, including but not limited to, any risks that are not foreseeable. I release the instructors and Advanced Response Training, from any and all liability and any and all claims, demands and causes of action for every kind and nature which I or heirs or members of my family may have arising out of incident to or in any way connected with my participation in this course. I also release the instructors and Advanced Response Training on behalf of my family as per the above. Participant's Name: ____________________________________ Signature: ___________________________________________ Date Signed: ___ ___ ______
		The following Media Release is Optional. I grant Advanced Response Training and those authorized on their behalf, the right to record my voice or person by photograph, record on film, videotape or in any other audio, visual, audiovisual medium or electronic media. I grant the non-exclusive right, license and privilege under copyright or other license enjoyed by me to use, broadcast, cable cast, reproduce and distribute in any form or format. Participant's Name: __________________________________ Signature: _________________________________________ Date Signed: ___ ___ ______

		Revised: January 3, 2006