WORKSHOP REGISTRATION FORM Complete form and send with $1270.00 ($1245.00 workshop fee + $25.00 processing fee) Cheque payable to FOCR (Friends of Channel Rock) or money order in Canadian or US Funds. Workshop selected Food Security 101 Dates Sept.19-26 2010 Channel rock has a variety of lodging available, including tents, tipis, yurts and beautiful cabins. All beds and bedding are of the highest quality, whether in a view cabin or tent. The costs of the workshop includes 3 meals a day and snacks made of organic ingredients whenever possible. In the summer, the majority of our produce is from our organic permaculture garden. Channel Rock does its best to meet the needs of those with environmental sensitivities. All of our buildings are built with natural materials, as much as possible sourced from our own land. Accommodations are carefully kept clean and mold free. Bedding is hypoallergenic and pillows and mattresses have allergy covers. Wool free Bedding available upon request. Please select your preference of accommodation: My Choice shared accommodation in our variety of lodgings private accommodation in an individual tent no preference First name Last name Email address Address City Province/State Postal Code Country Telephone Day Telephone Evening Applicant's Age Emergency Contact: Name Address Phone Relationship to applicant Medical Form Name Birth date Medical insurance plan (identify, i.e. blue cross etc.) Physical condition Allergies life threatening (none or ?) Allergies non life threatening (none or ?) Are you on any medications (prescription or non-prescription)? Yes, prescription Yes, non-prescription No If yes, please specify: Name of medications Reason for medications Have you been under a doctor's care in the past 12 months? Yes No If yes, please specify Do you have any physical limitations ? Yes No if yes, please explain By signing and dating the form below, I agree to the following: The above medical information is complete and accurate. If any of the information changes, I will inform Channel Rock so that the changes can be recorded. I understand that Channel Rock is in a remote location. I am in good physical condition to hike the trails. I agree to adhere to the rules and regulations set up by the the instructors of the workshop to minimize risk and ensure safety. I have read the Disclaimer of Liability (see below) of Channel Rock and agree to be bound by its terms and conditions. Disclaimer of liability: Channel Rock reserves the right to withdraw any itinerary or workshop without penalty and make alterations as necessary for a successful workshop. All arrangements made on behalf of Channel Rock shall be on the sole condition that we shall not be held responsible for any reason whatsoever, including negligence, for injury, illness, death or accident to participant or clients, or damage to or loss of personal property or for time or expense incurred, or for any irregularity which may be occasioned through acts of any persons and/or company connected with or otherwise engaged in carrying out the services described and in connection herewith. Please select one of the following payment options I am sending you the total of $1270 ($1245 workshop fee + $25 processing fee) I am sending you the total of $625 ($600 workshop fee + $25 processing fee), I have arranged my own lodgings. Name of Applicant Date I have read the cancellation policy This test prevents automated submissions Enter the text that appears in above image, then submit the form:
Complete form and send with $1270.00 ($1245.00 workshop fee + $25.00 processing fee) Cheque payable to FOCR (Friends of Channel Rock) or money order in Canadian or US Funds.
Workshop selected
Food Security 101
Dates
Sept.19-26 2010
Channel rock has a variety of lodging available, including tents, tipis, yurts and beautiful cabins. All beds and bedding are of the highest quality, whether in a view cabin or tent. The costs of the workshop includes 3 meals a day and snacks made of organic ingredients whenever possible. In the summer, the majority of our produce is from our organic permaculture garden.
Channel Rock does its best to meet the needs of those with environmental sensitivities. All of our buildings are built with natural materials, as much as possible sourced from our own land. Accommodations are carefully kept clean and mold free. Bedding is hypoallergenic and pillows and mattresses have allergy covers. Wool free Bedding available upon request.
Please select your preference of accommodation:
My Choice
shared accommodation in our variety of lodgings private accommodation in an individual tent no preference
First name
Last name
Email address
Address
City
Province/State
Postal Code
Country
Telephone Day
Telephone Evening
Applicant's Age
Name
Phone
Relationship to applicant
Birth date
Medical insurance plan (identify, i.e. blue cross etc.)
Physical condition
Allergies life threatening (none or ?)
Allergies non life threatening (none or ?)
Are you on any medications (prescription or non-prescription)?
Yes, prescription Yes, non-prescription No
If yes, please specify: Name of medications
Reason for medications
Have you been under a doctor's care in the past 12 months?
Yes No
If yes, please specify
Do you have any physical limitations ?
if yes, please explain
By signing and dating the form below, I agree to the following:
The above medical information is complete and accurate. If any of the information changes, I will inform Channel Rock so that the changes can be recorded. I understand that Channel Rock is in a remote location. I am in good physical condition to hike the trails. I agree to adhere to the rules and regulations set up by the the instructors of the workshop to minimize risk and ensure safety. I have read the Disclaimer of Liability (see below) of Channel Rock and agree to be bound by its terms and conditions.
Disclaimer of liability: Channel Rock reserves the right to withdraw any itinerary or workshop without penalty and make alterations as necessary for a successful workshop. All arrangements made on behalf of Channel Rock shall be on the sole condition that we shall not be held responsible for any reason whatsoever, including negligence, for injury, illness, death or accident to participant or clients, or damage to or loss of personal property or for time or expense incurred, or for any irregularity which may be occasioned through acts of any persons and/or company connected with or otherwise engaged in carrying out the services described and in connection herewith.
Please select one of the following payment options
Name of Applicant
Date
I have read the cancellation policy