Registration

Please print, fill in and mail this Application form along with your deposit to:

(Make checks payable to Marty Simon)

 Wilderness Learning Center

435 Sandy Knoll Road

Chateaugay, N.Y. 12920

 Name:___________________________________________________________________________

 Address:_________________________________________________________________________

 City_________________________________State__________________Zip Code_____________

 Day Phone______________________________Evening Phone__________________________

 E mail___________________

 Course Choices (Please use course code and date)

 1st Choice___________________________Date______________________________

 2nd Choice___________________________Date______________________________

 Age_______________Male______Female________

 Physical Condition: (describe)________________________________________________________________________________________________________

________________________________________________________________________________________________________

 Medications, allergies or special food requirements:___________________________________________________________________________________________

________________________________________________________________________________________________________

Where did you hear about us?_______________________________________________________

In case of emergency, please notify:

Name_____________________________________Relationship____________________________

Address_________________________________________________________________________

City________________________________State_________________Zip Code________________

Waiver & Release

I agree to abide by all the rules, regulations and safety procedures and all decisions of the instructors, or staff of the Wilderness Learning Center. I further acknowledge that I realize that taking a course in the wilderness has certain inherent dangers common to a wilderness setting and that I will not hold the Wilderness Learning Center, it’s instructors or staff liable for any injuries or accidents that may occur during the course. Furthermore I agree that my signature below is acceptance of these conditions.

Also I understand and agree that if I cancel 10 days or less from the start date of the course I will receive no refund of my deposit. If I cancel more than 10 days but less than 60 days from the start of my course I will be returned half of my deposit and the other half will be held for 1 year and applied to another course of my choosing at this school. Any cancellations over 61 days will receive a full refund.

All cancellations must be in writing, submitted by US Post (mail). Cancellation dates will be determined by postmark date.

 _____________________________________________                      ____________________________________

             Signature of applicant                                                Date