Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Gender *

We ask for this information so that we're able to make accommodations and safety as comfortable as possible for all parties. If you have any further questions please contact us at info@wildernessadventureoutreach.com.

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you have any current certifications? *

For example: first aid, swift water rescue, etc.

Yes

No

Do you have any conditions/illnesses that would inhibit/restrict your ability to participate in the program? *

Please note that these answers will be held in strict confidence and are only for your safety and that of your team.

Yes

No

Do you have any dietary restrictions we should be aware of? *

For example: Vegetarian, Vegan, Celiac, Lactose intolerant, etc.

Yes

No

May we contact you regarding future courses or promotions? *

Your information is confidential and will only be used for WAO reference.

Yes

No

I confirm that the information given on the above form is accurate and honest: *

Yes

No