Lifewater International: Community Health Through Hygiene

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COURSE REGISTRATION

Location: San Luis Obispo, California
Course Fee: $375 (Field Trainers eligible for reduced rate. See VTIC for details)
Registration Deadline: 5/14/12
On-site Training dates: 6/25/12 - 6/27/12

After completing this form, click the "Submit" button at the bottom of the page. Click "Pay Registration Fees" to make a course payment. You will be directed to the One Time Donation page. IMPORTANT: Please type CN-00138 in the comments field when submitting the course cost.

First Name *

Last Name *

Preferred Name (Nickname)

Email *

Please check for accuracy. Correspondence for this course is primarily through email.

Mailing Address *

Street address or PO Box

City *

State *

Enter the 2-letter state code

Zip *

Primary Phone *

(xxx) xxx-xxxx

Field Trainer Status *

Are you a certified Lifewater field trainer?

Yes

Applicant

Occupation *

Who is your current employer? If retired, indicate your primary career experience.

Organization

If you are taking this training as a part of another organization/ ministry, please identify the organization/ ministry.

Background

Briefly describe any community development or water-, sanitation-, or hygiene-related work experience you have. (Not a prerequisite for this class.)

Limitations *

Shallow Well Drilling, Hand Pump Repair, Latrine Design and Construction, and Biosand Filtration are physically active, hands-on, outdoor classes that involve lifting up to 35 pounds, using large tools, and working with machinery. Do you have any physical limitations that might make this difficult for you?

Yes

Not Sure

I am registering for a course that this does not apply to

Limitations

If you answered 'yes' or 'not sure' to the previous question, please explain.

Allergies

Please list all environmental and/or food allergies and any health conditions you have that may require special accommodation.

Course Notificiation and Refunds *

I understand I will receive an email from Lifewater within 2 days of the official registration deadline, informing me whether the course will go ahead as planned.

I understand that I will be responsible for my travel and lodging. I agree not to purchase airfare or make other non-refundable travel arrangements until I have received an email that the course is confirmed.

I understand that a $55 non-refundable deposit is due immediately and that full payment is due no later than 5 business days following official course confirmation.

I understand that after the official registration deadline, course payments are non-refundable.

Required

Submit

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