MEDIC SOLO Disaster + Travel + Wilderness First Aid sign-up form
NO prerequisite first aid training required for any class.
Learn from scratch, or come to recertify your WFA, AWFA, WFR or W-EMT.
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Welcome! Please choose a Course Location & Dates: *
YES, space is available if "spaces available" is written beside your desired class.  Your spot is confirmed once you've completed this form and PAID.  In-person classes run 8am - 7pm each day; on-time arrival and full attendance are required for education and certification.  
Your FIRST Name [and middle name (optional)] exactly as you wish to have it appear on your certification card *
If you have a dead name you do not have to enter that.  We warmly welcome you to use your current name.  However, documents requiring signature need to have your legal name, please.
LAST Name, exactly as you wish to have it appear on your certification card *
Email Address *
Have you taken a class before with MEDIC?  Which instructor?
Welcome Back!
*RE*certifying your Advanced WFA (4 days), WFResponder (8-10 days), or W-EMT? IF NO, LEAVE BLANK.  If Yes, enter ALL THREE items from your current cert card: {-1-} *School* (e.g. SOLO), {-2-} *Cert* (AWFA, WFR, or WEMT), and {-3-} *Expiration Date.*  Then see note below.
If you have a qualifying current cert, then you can take this class and receive a new cert from SOLO. The instructor will give you a form to mail to SOLO (requiring an additional payment directly to SOLO: $15 for WFR, or $25 for WEMT) *after* you successfully complete this class. If you have a SOLO cert and it will have expired shortly before this class, call SOLO at 603-447-6711 to secure an extension.
Your Birthday *
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Current Street Address *
Please enter your CURRENT local mailing address, where you'd like to receive course materials.
City *
State *
Zip (5 Digits Only) *
Cell Phone Number (10 digits straight please -- no spaces, hyphens, parentheses, nor a "1" at the front) *
If you don't have a cellphone, please enter the best number for reaching you on short notice
Daytime Phone Number, if different from the number above
Evening Phone Number, if different from the number above
How did you hear about this class? *
What prompted your taking this class?
You're **PRIMARILY** enrolling for: (check several if have several primary interests) *
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Why did you choose MEDIC?
Any particular questions or topics you'd like to have covered in this class?
Prior Trauma Storyline AVOID in class
Are there any hands-on scenario storylines (disaster / travel / wilderness / any) which you do NOT want used in class, due to prior trauma / painful memories?
Discomfort acting as an unconscious, eyes-closed patient
During class scenarios, fellow students will act as your caregivers, practicing what they've learned.  Please note here if you'd feel uncomfortable acting as an unconscious, eyes-closed patient during a scenario.  If yes, will ask you to play eyes-open roles only, when it's your turn to act as a patient.
Please read and verify: *
Obligatoire
And finally, *
*Thank you* for helping us serve you.
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FINAL STEPS:  AFTER clicking the submit button below, SCROLL DOWN to all REQUIRED FINAL STEPS BELOW. Enter here any further notes to us.
Thanks! If you have comments/questions you can leave them here, or call 434-326-4697.  Please advise us of any changes to your answers above, at least 3 weeks before class, to avoid a late change fee.
MAKE SURE THIS QUESTIONNAIRE DISAPPEARS when you click the Submit button.  IF IT DOESN'T, YOUR ANSWERS DID NOT COME THROUGH.  In this case, please scroll up, look for error messages, and keep submitting until the questions disappear.  THEN SEE FINAL STEPS BELOW to complete your registration. *Thank you!*
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Ce formulaire a été créé dans MEDIC SOLO Wilderness First Aid + Responder Course.