Month, Year- Until Help Arrives Course Application
This is the application for the Until Help Arrives course hosted in (city). The course is held on (date) from (start time) to (end time). The course is open to all abilities and persons who are at least 13 years old. Please complete all portions of this application to be eligible for enrollment. If you need to cancel your application please contact Greater Nashua Public Health at 603-589-4569 or by email at cert@readynashua.org.
Email address *
Confirm Email Address *
First Name *
Last Name *
Address *
Town/City *
State *
Zip Code *
Phone *
How did you find out about us? *
Please list any accommodations you may need for the class.
I agree to hold the City of Nashua, and their agents and personnel, harmless from any and all claims, actions, suits, and/or injury that I may suffer and which may arise as a result of my participation in the above mentioned class. I hereby give my consent, in the case of injury or illness, to have a medical doctor, nurse, hospital, clinic, or other medical practitioner provide me with medical assistance and/ or treatment, and agree to be responsible financially for the reasonable cost of such assistance and/or treatment. I also consent, in the case of injury or illness, to first aid treatment. Informed Consent for Release of Information: By checking below, I grant permission for Office of Emergency Management, the City of Nashua, and its affiliates to use my name; any photos, film, or videos of me or my likeness; and/or any other identifying information about me, in legitimate accounts of my work and experience as a participant. By executing this release I certify that I have read this release in its entirety, understand all of its terms and have had any questions regarding the release or its effect satisfactorily answered. I sign this release freely and voluntarily. *
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