SIRIUS - Wilderness Medicine

Enrolment in all courses is limited. To reserve a space, please send in this registration form along with the course fees and applicable sale tax (GST, PST). Upon receipt of registration and course fees a letter of confirmation will be sent to you along with course details, map and information related to your course. If for any reason SIRIUS WILDERNESS MEDICINE is obliged to cancel a course, you will be entitled to full refund.

Our registration form can also be printed and faxed / mailed to us at:

SIRIUS WILDERNESS MEDICINE
1158 rue Duquette
Val-David QC, Canada J0T 2N0
Tel: (514) 509-2112 • Fax: (514) 509-2123

On-line Registration Form

Personal Information Please note that each participant must complete a registration form individually.
First name:
Last name:
Street:
City:
Prov/State:		Postal Code:
Country:
Tel# Home:	(000) 000-0000	Tel# Work: ext:
Fax #:	(000) 000-0000
Email:

Course Selection

Enter the Course ID number from the course calendar of the course which interest you. Please note that the Course ID refers to a specific course type, date and language of instruction.

Course ID:		e.g.: WFA2-1234 Please enter a valid Course ID from the course calendar.
Recertification:		Please specify if you are recertifying a past certificate that is still valid
Lodging:		Are you interested in accommodation and meals for the duration of the course? Please contact the office for details and costs. If you have dietary restrictions or allergies, please let us know in the Information field below.
CPR:		CPR is a prerequisite for all of our courses. Please confirm whether or not you wish to pre-register for the CPR portion of the course. This is at an extra cost of 50$ + taxes.

Payment Options

Please make your check or money order payable to SIRIUS WILDERNESS MEDICINE INC.
Payment method:		Total:
Credit card number:	(Visa or Mastercard number)	Expiration date:	(mm/yyyy)
	*Please note that credit card payments can also be processed over the phone* *Prices exclude tax. Applicable federal and provincial sales taxes will be added to the final amount*

Extra Information :

How did you hear about us?

1158 rue Duquette
Val-David QC, Canada J0T 2N0
Tel: (514) 509-2112 • Fax: (514) 509-2123
Email: info@siriusmed.com
TOLL FREE in Canada: 1 (877) 982-0066

Copyright © 1996-2010 Sirius Wilderness Medicine Inc.