Wilderness First Aid Class Sign-Up Sheet

CONTACT INFO:

Name
Email
Phone (day)
Phone (night)
Emergency Contact Phone
Medical Insurance Company
Medical Insurance Policy No.

TRIP INFO:

Dietary Restrictions

TRANSPORTATION:

I have a car I'm willing to drive. It holds people including the driver,
       canoes and bicycles.
I'm 25 or older and I'm willing & able to drive a van rented by MITOC.
I need a ride. Will you please find me one?

MEDICAL:

Please list allergies or medical conditions you have:

Do you have medical training? No
Yes --  what level? 

Form created Greg Galperin. If you have problems, contact hbriceno@mit.edu