REGISTRATION FORM 
 
Enrollment 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. 
 
Name:____________________________________________

Tel# home: _______________) tel# work: _________________ 

Address:_______________________________________________________________
_______________________________________________________________________

_______________________________________________________________________ 
		
fax #:________________________________________
	Internet address: __________________________________ 

course ID:_________________ 

Visa/Mastercard number:_______________________ 

Expiration date: ________________ 

Total: ________________
			
				
Signature of participant	____________________________________