Custom Program Instruction

Select The Dates You Would Like To Attend:*

Student Information

Legal Name*

First Last

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

How Did You Hear About Us?*

Emergency Contact

Emergency Contact Name*

First Last

Relationship*

Emergency Phone*

Emergency Email*

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Personal Information

T-Shirt Size - Unisex*

Extra Small
Small
Medium
Large
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2X Large

Height (ft)*

Height (in)*

Weight (lbs)*

Age*

Parent/Guardian Name*

First Last

Parent Guardian Email*

Medical Information

Wilderness Leadership Institute (WLI) requests this information to assist staff in the management of courses and in the emergency response of medical conditions that any participant or observer may have. This information will remain protected and confidential. By requesting this information, WLI does not imply that we have the expertise to assess your physical condition or your ability to participate in this course. This determination of ability must be made by you, the participant, in concert with your physician.

Please list any relevant medical or psychological conditions that you are currently managing or have had in your past (Enter 'None' if not applicable)*

Note: The following list is a non-exhaustive list of conditions that may be pertinent: musculoskeletal injuries, cardio-respiratory system problems, neurologic conditions, allergies (environmental, food, etc.), blood sugar management, heat or cold injury…

Please list any medications that you take on a regular or periodic basis, and the typical dosage (Enter 'None' if not applicable)*

I understand and acknowledge that Wilderness Leadership Institute is not making a determination of my fitness for a course; rather, I represent to Wilderness Leadership Institute and verify that I am physically fit and ready for the course. I have read and agree to the terms and conditions of the "Cancellation & Refund Policy".*

Confirm

Download the WLI Cancellation & Refund Policy.

Climbing Course Information

Please describe your climbing experience in detail (Enter 'None' if not applicable)*

Men's Shoe Size*

Waist Size*

Select The Number Of Attendees*

BY CHECKING THIS BOX, I REPRESENT TO WLI THE FOLLOWING: I UNDERSTAND THAT FOR THE PURPOSE OF REGISTRATION, THE WORD “PROGRAM” IS DEFINED TO INCLUDE ALL WLI RELATED ACTIVITIES. I HAVE READ AND AGREE WITH WLI’S CANCELLATION AND REFUND POLICY, WHICH MEANS THAT I WILL LOSE MY SECURITY DEPOSIT OR RECEIVE ONLY A PARTIAL REFUND OF A PROGRAM FEE IF I CANCEL MY REGISTRATION REGARDING SUCH PROGRAM. I UNDERSTAND THAT ALL SALES ARE FINAL REGARDING ALL PROGRAMS, WHICH MEANS THAT I DO NOT HAVE THE RIGHT TO A REFUND IF (A) I TERMINATE MY PARTICIPATION IN A PROGRAM, (B) I DO NOT LIKE A PROGRAM, OR (C) I DO NOT OBTAIN A CERTIFICATION AS RESULT OF ATTENDING A PROGRAM. I UNDERSTAND THAT ALL REFUNDS REGARDING A PROGRAM ARE GOVERNED BY THE TERMS AND CONDITIONS THAT ARE PUBLISHED ON THIS WEBSITE, AND THAT WLI RESERVES THE RIGHT TO AMEND, WITHOUT NOTICE, THE TERMS AND CONDITIONS THAT ARE PUBLISHED ON THIS WEBSITE.

Comfirm

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$0.00

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Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

You will be redirected to sign an acknowledgement of risk following the completion of this form. Please review and digitally sign the documents to complete your registration.

Phone

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