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NICA Course Request
Thank you for choosing to run a course through AdventureMed. Please submit the following information, and we will follow up with you within the next 48 business hours. If you have any questions, please reach out directly to
info@adventuremed.com
General Information
League
(Required)
Start Date
(Required)
MM slash DD slash YYYY
Start Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
End Date
(Required)
MM slash DD slash YYYY
End Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Location
(Required)
Will this class include CPR?
(Required)
Yes
No
Instructors
Lead
(Required)
Assistant(s)
Registration
Date registration will close
(Required)
MM slash DD slash YYYY
Max # of participants
Registration Fee (if different than recommended $100):
Student Communication
AdventureMed to send pre-course email
(Required)
Yes
No
Payment
Payable Party
(Required)
Payment Method
(Required)
Direct Deposit
Mailed Check
If the payable party wants to receive payment via direct deposit, ensure a direct deposit form has been sent to AdventureMed prior to the start of the course.
If the payable party wants to receive payment via a mailed check, ensure that address is confirmed prior to the start of the course.
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