Emergicare Medical Training Application

(Print form and mail into register for classes)

Individual enrollment in all Backcountry Trail Patrol Association/Emergicare Medical Training, Inc. (Emergicare) courses is limited. To reserve a space in an Emergicare course, please return your application form and the appropriate tuition/deposit to Emergicare. Courses $250.00 and under require tuition payment in full at the time of registration. Full, non-refundable and non-transferable tuition, is due 14 days prior to the course. However, in the event of a student being unable to attend a course they have registered for, their payment may be applied to another Emergicare course at the same level, upon approval by Emergicare Medical Training. Prior to 14 days before the course date, tuition may be refunded, minus a 15% administrative fee.

If a program is cancelled by Emergicare due to low enrollment, the full deposit/tuition will be refunded. 

REGISTRATION INFORMATION

Name: ___________________________________________________

Email: ___________________________________________________

Address: __________________________________________________

City: ______________________ State: ______ Zip: ______________

Phone: ____________________ Permanent Phone: ________________

Course Dates:______________ Course Location:_________________

Will you be 18 when the course starts? Yes ____ No ____ (Students under 18 must have parent/guardian consent)

Are you recertifying certification? Yes ____ No ____ (If "yes" please bring a copy of the certification card to the course)

Course recertifying: WFA ____ WAFA ____ WFR ____ Certification from:_____________

PAYMENT AMOUNT: (See below) ___________________

Trail Club Affiliation (For discount)  ______________________________

I the undersigned understand and agree that all course deposits are non-refundable and non-transferable under all circumstances, except as noted above.

Signature:_________________________________________________________

 

 

 

COURSE INFORMATION AND COSTS:

36 Hour Wilderness First Aid (includes textbooks and CPR certification) $250.00

WFR Refresher $125.00

Single Rescuer CPR  Free-Courtesy of Team Ortho Foundation

Make all checks payable to "Emergicare Medical Training", with the notation "AWFA" in the

"note" line, and mail to:

Emergicare Medical Training

c/o Backcountry Trail Patrol Association, Inc.

28950 Tamarack St. NW

Isanti, MN 55040