Student Information

Thank you for registering with Coast Wilderness Medical Training. We require a bit of additional information - please fill out the form below. If you have any questions or concerns, please contact us at (778) 554-3731.

Name

First Name

Last Name

Any Questions?

What brought you to Coast?

If you were referred, please let us know who referred you in the comments below, so we can thank them!

Allergies

Relevant Medical History

Please let us know of any medical conditions or recent surgeries that you think your instructor should know about.

Emergency Contact

Name, phone, relationship