ࡱ > ; = : y P bjbj 4 { { P ` ` ` ` ` t t t t $ t > @ @ @ @ @ @ $ 3 d ` d ` ` y ` ` > > ȃB . * 0 ~ ` \ C l 5 U d d L & : Blue Otter School of Herbal Medicine Backpacking Trip 2012 Registration Form (Please feel free to use separate paper if necessary) Name: Birth date: Address: Gender: Phone: Email: ***************************************************************** 1. What previous courses have you taken or experience do you have in herbal medicine and/or the health field? 2. How did you hear about the Blue Otter School of Herbal Medicine? 3. Why are you interested in taking this course? 4. What previous experience do you have with backpacking and/or hiking? 5. Do you have, or have you ever had, any physical or mental health issues (if yes, please elaborate)? __ Please share my contact information with others attending this course to facilitate carpooling. __ Enclosed is my non-refundable deposit of $50 for each trip, payable to Blue Otter School, to hold my space. The balance of the trip fee ($225) is due 2 weeks prior to the trip. I am signing up for the following backpacking trip(s): __ August 10-12: Eddy Mountains - $275 __ August 17-19: Marble Mountain Wilderness - $275 Emergency contact: (name and phone) __________________________________ At the Blue Otter School of Herbal Medicine, we are dedicated to providing a safe space for all students to learn and to work without bigotry or prejudice present. To this end, we will not tolerate any form of prejudice based on (including but not limited to); race, ethnicity, religion, country of origin, gender, sexual orientation, physical or mental ability, size or socio-economic status. No violence will be tolerated, verbal or physical. Absolutely no weapons or illegal substances are allowed on school premises or school trips. You will be immediately dismissed without a refund for breaking these rules. The materials and knowledge given at the school may not be copied, distributed, used as teaching materials or published without prior written consent from Karyn Sanders and Sarah Holmes who own copyrights to all materials. Blue Otter School of Herbal Medicine is not responsible or liable for injuries that occur on or off-site during the time you are attending school, or the physical or emotional health of people attending the school. Students are responsible for providing their own prescription medications, including an epi-pen if allergic to bee stings, and understand that most of the time we will be at least two hours from a hospital. Students are also responsible for arranging their own transportation to and from trailheads, all equipment needed, food (except Friday and Saturday dinners) and water. I have read, understood and agree to the above terms. The information I have provided is true and accurate. Signature: ___________________________________________ Date: _______________ 13310 Patterson Creek Road, Fort Jones, CA 96032 * (530) 468-4342 * info@blueotterschool.com % : < N O D G R i j o ܼܗ{{p{{{h{_{ h