Private Course Request – Lay Rescuer - AdventureMed

Name of Organization(Required)

Email Address(Required)

Phone Number

Location (including address)(Required)

Proposed Location of Course (if different from organization address)

Note: does your location have a whiteboard/AV capability and an easily accessible outdoor space?

Proposed Date(Required)

Please provide, if possible, both an ideal exact date and range of possible dates

Why do you want a wilderness medicine course?

Estimated number of students(Required)

Please enter a number greater than or equal to 8.