Address State, Zipcode Email Address Sponsor Name Course

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Course Number

Date

Student’s Name

Birthdate

Address

City

State, Zipcode

Phone Number

Email Address

Sponsor Name Course Location

I ,____________________________________, a parent or guardian of ____________________________________, understands that my son/daughter will participate in the Wilderness Medical Associates® ________________________________ course being held at ____________________________________ from _________ to __________. I realize this is a course dealing with human anatomy and physiology, and will require working closely with and physically assessing (touching) other students and have other students assess (touch) them. My son/daughter will be taught how to handle medical emergencies in remote or limited resource areas; and also be responsible for the evaluation, assessment, and treatment of patients that will be supervised by a WMA trained instructor. Thus, I do, therefore, permit ____________________________________ to enroll in this course. __________________________________________ Parent or Guardian Signature

Rev 06/2013

_____________________________ Date

Face any challenge, anywhere.

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