Wilderness First Aid Participant Survey April 18 – April 19 @ National Great Rivers Museum Your InformationName(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Gender(Required) Male Female Prefer Not To Say Military Status(Required) Veteran Active Duty or Reserve None About YouCurrently First Aid Certified?(Required) Yes No Have you previously been CPR/AED certified?(Required) Yes No Allergies to anything?(Required) Yes No Please list all known allergies, including food and medications etc. and how you will manage this(all answers are kept confidential)Do you have any physical, mental, or medical conditions that you feel could affect your participation?(Required) Yes No Please give a detailed explanation (all answers are kept confidential)(Required)Curently taking medications? (all answers are kept confidential)(Required) Yes No Please list (all answers are kept confidential)(Required)Please list prior trainings/certifications pertinent to this courseACA WaiverThe following release and assumption of risk must be read, agreed to and signed on site the first day of class as a condition of participation Waiver / Release I have read and understood the above document and agree to sign a paper copy of this document upon arrival at course locationEmergency Contact InformationContact's Name First Last Contact's Phone Δ
