Swiftwater Rescue Course Application, 2013

To enroll, please confirm availability by calling Program Director Steve Harris at 575-751-1269, emailing him at This e-mail address is being protected from spambots. You need JavaScript enabled to view it or contacting sponsor at: Far-Flung Adventures Box 707 El Prado, NM 87529
toll-free: 800-359-2627, fax 575-776-1443, e-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Registration closes 14 days prior to start of course. Applications must be received before that time.

Please enroll ___ persons in :

___Swiftwater Rescue for River Professionals on Date:__________

Name(s): ________________________________ Age: ____ Height:___' ___" Weight:________

Address:
___________________________________________________________________________

City: _________________________________ State: __________________ Zip: _____________

E-Mail (important for receiveing reading materials)____________________________________

Affiliation:
_________________________________________________________________________ ___

Work Phone: ________________________________ Home: ____________________________

Reason For Seeking Enrollment:
________________________________________________________

Swiftwater Hazards In My Area:
_________________________________________________________


PAYMENT ENCLOSED: Tuition Amount: $__________________.


____ I request an Invoice to accompany attached purchase order #______________


_____Check Or Money Order (Payable To Far Flung Adventures)


_____Bill My Major Credit Card: ___Visa___Mastercard___American Express___Discover


Card #_______________________________________Expiration Date_________


By signing below, I (authorize use of credit card for amount stated)/certify that I have basic
swimming ability, am in good health, have (or can obtain) personal protective gear as outlined in gear
checklist, and am able to participate in course.
Signature: _________________________________________________ Date: _________