APPLICATION FOR EARTH CONNECTION NORTH CAROLINA

All applications must be submitted by mail with full payment per course.     
Sorry, but no email applications can be accepted.   This application is for Earth Connection NC ONLY.
All applicants must be 18 or older.                         
Please fill out the following form, PRINT, SIGN and MAIL along with tuition payment to:  

Earth Connection North Carolina

6118-J Farrington Road

Chapel Hill, NC 27517
Please identify yourself: Please provide the following contact information:
Name
Age
Sex Male Female
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail
Emergency Contact Name and Phone Number:
Do you have any special dietary needs or are you a vegetarian?   NO    YES 
Do you have any allergies to foods, medications and/or insects; or any health concerns of which we should be aware? If yes please explain:   
 NO    YES 
Please select the course(s) for which you are registering:   Enter the date of the course you would like to attend:
What are your goals for this (these) course(s)?
How did you hear about us?

WAIVER (all applicants must read and sign this waiver)
In all courses, events and excursions conducted by Earth Connection - it�s assistant instructors, helpers, Wes Massey, Hardee Merritt and Todd Magers, individually - reasonable care is taken to prevent serious injuries and  minimize accidents. The student states that he or she is in good physical and mental health; and fully aware that survival, primitive technology, eating wild plants, and wilderness travel may be dangerous. The student by signing their name below hereby agrees to accept full responsibility for themselves and assume all risks, including those caused by acts of God, injury, death and/or loss to his or her person and/or property. The student hereby waives all present and future rights to make any claims resulting in any way from attending current or future courses, events or excursions conducted by Earth Connection, its assistant instructors, helpers, and staff, individually.  
Signature of Student:                Date: 
(DO NOT TYPE - MUST BE WRITTEN SIGNATURE)
OPTIONAL - By initialing below, the student releases Earth Connection to use photographs taken during courses which may contain images of the student, for Earth Connection's advertising purposes.  
Student's Initials:  (Do Not TYPE- Must be Written Initials)                

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