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Application

Part 1: Registration Information

All applicants must be 18 or older, except for family courses and events.

Name*
Age*
Sex Male
Female
Address 1*
Address 2
City*
State/Province*
Zip/Postal Code*
Country
Work Phone
Home Phone
E-mail*
Emergency Contact Name*
Emergency Contact Phone Number*
Do you have any special dietary needs or are you a vegetarian? No
Yes
If yes, please explain:
Do you have any allergies to foods, medications and/or insects; or any health concerns of which we should be aware? No
Yes
Is yes, please explain:
Discount Code:
Please select the course(s)for which you are registering:
Course 1*
Date*
Course 2
Date
Course 3
Date
What are your goals for this (these) course(s)?
How did you hear about us?
Waiver
(all applicants must read and sign this waiver):
In all courses, events and excursions conducted by Earth Connection - it’s assistant instructors, helpers, and Tim MacWelch, individually - reasonable care is taken to prevent serious injuries and minimize accidents. The student states that he or she is in good physical and mental health; and fully aware that survival, primitive technology, eating wild plants, and wilderness travel may be dangerous. The student by signing their name below hereby agrees to accept full responsibility for themselves and assume all risks, including those caused by acts of God, injury, death and/or loss to his or her person and/or property. The student hereby waives all present and future rights to make any claims resulting in any way from attending current or future courses, events or excursions conducted by Earth Connection, its assistant instructors, helpers, and Tim MacWelch, individually.
Signature of Student*
Date*
Optional:
By initialing below, the student releases Earth Connection to use photographs taken during courses which may contain images of the student, for Earth Connection's advertising purposes.
Student's Initials
Payment Method:

Please note: Submitting this form registers you for the class(es) specified above.

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Contact Information
Telephone: 540-270-2531
Mailing Address: PO Box 32 Somerville VA 22739
Travel Directions: Directions to our locations are given out AFTER registration in a class.  There are no travel directions posted on this website.
Email: econnect@earth-connection.com