Choose Course Location & Date:

First Name

Last Name

Email *

Phone *

Have you taken a class before with MEDIC? Which Instructor?

Re-certifiying your Advanced WFA (4 days), WFResponder (8-10 days) or W-EMT? If no, leave blank. If yes, please enter ALL THREE of the following items from your current cert car: (1) School (e.g. SOLO), (2) Cert (AWFA, WFR, or WEMT), and (3) Expiration Date

If you have a qualifying current cert, then you can take this class and receive a new cert from SOLO. The instructor will give you a form to mail to SOLO (requiring an additional payment directly to SOLO: $15 for WFR, or $25 for WEMT) *after* you successfully complete this class. If you have a SOLO cert and it will have expired shortly before this class, call SOLO at 603-447-6711 to secure an extension.

Date of birth *

Address *

City *

State *

Postal code *

Country *

How did you hear about this class? *

What prompted you taking this class?

You're **primarily** enrolling for: *(check all that apply as primary interests)

Why did you choose MEDIC?

During class scenarios, fellow students will act as your caregivers, practicing what they've learned. Please note if you'd feel uncomfortable acting as an unconscious, eyes-closed patient during a scenario.

If yes, we will ask you to play eyes-open roles only, when it's your turn to act as a patient.

Any particular questions or topics you'd like to have covered in this class?

Are there any hands-on scenario storylines (disaster / travel / wilderness / any) which you do NOT want used in class, due to prior trauma or painful memories?

Optional: I choose to pay by Venmo, PayPal or check

Venmo: Send to @MEDIC or Matthew Rosefsky (include the space between Matthew and Rosefsky); blue & green MEDIC symbol should appear. If Venmo asks: last 4 digits of phone number are 8733. If you choose the option to add Insurance, please add $10 to the total.

PayPal: Please choose "Friends and Family" option if your account has it (then we won't lose a commission to PayPal) and send to medicwfa (at) gmail (d0t) com. Pre-existing Special Deals: add $7 if you don't see the "Friends & Family" option when you are in the PayPal send-money area. If you choose the option to add Insurance, please add $10 to the total.

Check: Check / Money Order: Make the check/money order out to "MEDIC" and mail to: MEDIC, 351 10th Street NW, Charlottesville, VA 22903

Payment plan: I am interested in paying in installments and want someone to follow-up with me about options.

I understand my registration is not processed until full payment is received.

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.

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