Registration Form

Wilderness First Aid Certificate

 

Monday 5th to Thursday 8th October 2009

Monday 14th to Thursday 17th December 2009

 

Please print then mail or fax to the address above.

$640.00 per person

Organisation

 

Name

 

Gender (Please Circle)

Male           Female

Address

 

Town

 

State

Postcode

Email

 

Phone (work)

 

Phone (mobile)

 

Special dietary requirements

 

 

 

Other (eg Medical info)

 

 

 

 

 

 

 

 

 

PAYMENT OPTIONS:                                                            

□   $220.00 DEPOSIT on registration, with balance paid by 20th April 2009

□   Pay in full $640.00 per person

 

PAYMENT METHODS:

□ By cheque made out to ‘Laurel Hill Forest Lodge’ Mail to 1670 Batlow Road Tumbarumba 2653

□ By direct deposit Westpac Bank Details: Laurel Hill Forest Lodge BSB 032 766 Account No.112395

□ By credit card. When you send your registration form request a pay pal tax invoice which we will email back to you. Please note a surcharge of 2.5% applies to this method of payment

 

 

Maximum 15 participants, course will be postponed if numbers are not achieved.

 

 

Signature                                                                                                                    Date