Earth Connection:

Earth Connection Registration

Please fill-out the form below to register.

Registration Form

Personal Information

First Name *

Last Name *

Age *

Gender *

Military/Law Enforcement/Fire/Rescue *

Address Information

Address 1 *

Address 2

apartment, suite, etc.

City *

State *

Zip *

Country

if outside the US

Contact Information

Mobile Phone *

In case we need to call you while you're traveling to and from class.

Home Phone

Or evening phone

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Health Information

Do you have any health concerns of which we should be aware? *

allergies to food, insects, medication, etc.

If yes, please explain

Course Information

Course 1 *

Date *

Format: MM/DD/YYYY

Course 2

Date

Format: MM/DD/YYYY

Course 3

Date

Please tell us what percentage of these three topics motivated you to join us. Outdoor skills/ Disaster Preparedness/ Fun & Recreation *

Example: 60/30/10

How did you find us? *

Discount Code

If you have a discount code, enter it here.

Waiver

All applicants must read and sign this waiver.

In all courses, events and excursions conducted by Earth Connection - its assistant instructors, helpers, and Tim MacWelch, individually - reasonable care is taken toprevent 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 Tim MacWelch, individually.

Signature of Student *

Date *

May we use your photos? *

By selecting yes above, the student releases Earth Connection to use photographs taken during courses which may contain images of the student, for Earth Connection's advertising purposes.