Intro to Wilderness Medicine Sign Up

First Name

Last Name

Email

Phone Number

Birthdate

Shirt Size

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Allergies

Emergency Contact Name (First and Last)

Emergency Contact Phone Number

Emergency Contact Email

Prior Outdoor Experience

Please take a moment to share with us your level of experince outdoors (activities you have done, certifications you may have, experince in the mountains, etc.)